5 and PRACTICE : 



EEDING 



HESS,M.D. 




Glass _KJJ&lk 
Book _ . H 4 



Copyright N°_li£JL 



COPYRIGHT DEPOSIT. 



Principles and Practice of 
Infant Feeding 



BY 

JULIUS H. HESS, M.D. 

Professor and Head of the Department of Pediatrics, University of 

Illinois College of Medicine; Chief of Pediatric Staff, Cook County 

Hospital; Attending Pediatrician to Cook county, Michael 

Reese and Englewood Hospitals; Consulting Pediatrician, 

Municipal Contagious Hospital, Chicago, Etc. 



ILLUSTRATED 



THIRD REVISED AND ENLARGED EDITION 




PHILADELPHIA 

F. A. DAVIS COMPANY, Publishers 
1922 






COPYRIGHT, 1918 
COPYRIGHT, 1919 
COPYRIGHT, 1922 



F. A. DAVIS COMPANY 



Copyright, Great Britain. All Rights Reserved. 



PRINTED IN U. S. A. 

PRESS OF 

F. A. DAVIS COMPANY 

PHILADELPHIA. PA. 



OCT -9*22 



At)o3588 



TO 

ISAAC A. ABT, M.D. 

MY FRIEND AND TEACHER 
THIS BOOK IS AFFECTIONATELY DEDICATED 



PREFACE TO THIRD EDITION. 



In the preparation of the third edition the chapters on 
Vomiting, Colic and Flatulence, Constipation, and Ab- 
normal Stools have been completely rewritten. 

The classification, nomenclature and pathogenesis of 
the nutritional disturbances have been revised to conform 
to the latest researches. American clinics are to be 
credited with the greater part of this progress. 

New chapters dealing with rickets, scurvy, spasmo- 
philia, acidosis and anemias of infancy have been added. 

Julius H. Hess. 

Chicago, Illinois. 



(v) 



PREFACE. 



It has been our experience that the best results ob- 
tained in the teaching of the principles and practice of 
infant feeding have been accomplished when the theory 
of feeding and the study of actual cases have been 
combined. 

Our object in publishing this volume is to place in 
the hands of teachers and students a manual on infant 
feeding to be used in preparation for clinical confer- 
ences. Whenever possible, the subject under discussion 
is illustrated in the class-room by clinical cases and case 
records from the teacher's personal material. 

While there are many excellent works covering this 
subject, we have found most of them to be too volum- 
inous to fulfill our needs, and we have therefore at- 
tempted to present the subject in concise form in this 
small volume. 

For the teaching of nurses we have selected those chap- 
ters which have to do with the nursing care of premature, 
healthy, and sick infants, the feeding of breast-fed and 
artifically fed healthy babies, and the preparation of in- 
fants' foods and diets. 

Julius H. Hess. 

Chicago, Illinois. 



(vii) 



CONTENTS. 



Part I. 

GENERAL CONSIDERATIONS. 

CHAPTER PAGE 

I. — Anatomy of the Digestive Tract of the Infant 1 

II. — Physiology of the Digestive Tract of the Infant 3 

III. — Metabolism in Infants 6 

IV. — Bacteria of the Digestive Tract of the Infant 27 

Part II. 

THE NURSING. 

I. — General Considerations 35 

II. — Maternal Nursing 38 

III. — Wet-nursing 46 

IV.— The Nursing Infant 61 

V. — Mixed Feeding and Weaning 63 

VI. — Nutritional Disturbances in the Breast-fed Infant 67 

VII. — Methods of Feeding Premature Infants 84 

Part III. 

ARTIFICIAL FEEDING. 

I. — Recent Progress in Artificial Feeding 100 

II.— Cow's Milk 103 

III.— Adaptation of Milk for Infant Feeding 115 

IV.— Milk Dilutions with Addition of Carbohydrates 119 

V. — Cream and Skimmed Milk Mixtures 155 

VI. — Feeding in Late Infancy and Early Childhood 158 

Part IV. 

NUTRITIONAL DISTURBANCES IN ARTIFICIALLY 
FED INFANTS. 

I. — Minor Disturbances 162 

II. — General Consideration of Nutritional Disturbances 187 

III. — Nutritional Disturbances Unassociated with Diarrhea .. 200 

(ix) 



X CONTENTS. 

CHAPTER . PAGE 

IV. — Nutritional Disturbances Characterized by Diarrhea . . 218 

V. — Athrepsia ( Decomposition ) 237 

VI. — Anhydremia (Anhydremic Intoxication) 259 

VII. — Infection and Nutrition 276 

Part V. 
Rickets (Rachitis) 30+ 

Part VI. 
Spasmophilia 341 

Part VII. 
Scurvy 358 

Part VIII. 
Acidosis 384 

Part IX. 
Anemias of Infancy 405 

Appendix 425 

Index 485 



ILLUSTRATIONS. 



FIG. PAGE 

1. — Proper method of holding baby during nursing 57 

2. — Author's improved breast-milk collector 58 

3. — Direct expression of breast-milk, Act 1 59 

4. — Direct expression of breast-milk, Act 2 60 

5. — Breck feeder for premature infants 87 

6. — Apparatus for gavage and lavage 88 

7. — Feeding baby with catheter 89 

8. — Scale for weighing infants 121 

9. — Infant with athrepsia 237 

10. — Chart of infant with athrepsia 245 

11. — Chart of infant with parenteral infection 283 

12.— First stage of rickets 322 

13.— Rickets after 28 days treatment 323 

14. — Rickets after 43 days treatment • 324 

15. — Rickets, extreme degree 326 

16. — Enlarged megalocolon and sigmoid in rickets 327 

17. — Extreme changes in rickets 328 

18. — Spasmophilia 350 

19. — Spasmophilia 352 

20. — Spasmophilia, Trousseau's sign 353 

21. — Spasmophilia, fractures of radius and ulna 356 

22. — Scurvy in guinea pig 363 

23. — Scurvy — '"White Line" of Fraenkel 368 

24. — Scurvy with hemorrhage into knee joints 369 

25. — Scurvy with hemorrhage about tibia and fibula 371 

26. — Scurvy. Typical lesions of the gums (colored) . . facing 372 

27. — Scurvy, bilateral proptosis 375 

28. — Utensils used in artificial feeding 445 

29.— Nursing bottles 448 

30.— Milk station 449 

31.— Hospital bathroom 452 

32.— Hess bed 462 

33. — Diagram of Hess bed 463 

34. — Receptacle for heating pads (electric) 464 

Case records '. 471 to 484 



(xi) 



LIST OF TABLES. 



PAGE 

Classes of food-stuffs 20 

Weight gain 121 

Percentage of different salts in human and cow's milk 133 

Caloric requirements for the artificially fed infant 136 

Caloric values of various foods 138, 146 

Data as to foods and food requirements 139 

Food elements required per pound, body weight 140 

Equivalent weights and measures of carbohydrates 143 

Elements in milk mixtures 147 

Formula for feeding 148 

Proper ingredients for child of 8 months 150 

Diet for new-born infants during first four weeks 151 

Condensed milk content 429 

Average weights 466 

Measurements 467 

Eruption of deciduous teeth 468 

Eruption of permanent teeth 468 

Average daily quantity of urine in health 469 

Average rate of pulse and respiration 469 



(xiii) 



INTRODUCTION. 



The dependence of the offspring upon its mother for 
food to supply its primitive needs can only be realized 
when we remember that one-fourth of the civilized race 
die during the first year of life, and that 60 per cent, of 
these deaths are due to nutritional disturbances, while a 
large portion of the other 40 per cent, are primarily de- 
pendent upon impairment of the infant's constitution by 
improper feeding. The mortality of the first year is 
nearly 60 times that of the fifteenth year, and it is not 
until we approach the 85th year that we meet with such 
a high percentage death-rate. The problem is not simply 
to save life during the perilous first year but to adopt 
those means which shall tend to healthy growth and nor- 
mal development. The child must be fed not only to 
avoid the immediate dangers of acute indigestion, diar- 
rhea, and marasmus, but the more remote ones — rickets, 
scurvy, and general malnutrition. These latter three are 
the most important conditions that predispose to disease 
in early life. 

A growing child requires far more food than its 
weight would indicate. For, in the first place, its intake 
must exceed its expenditure, so that it may grow. The 
expenditure of an organism is pretty nearly in propor- 
tion, not to its mass, but to its surface. The skin surface 
of a boy from 6 to 9 years, with a body weight of 18 to 
24 kilograms (40 to 50 pounds), is two-fifths to one-half 
that of a man of 70 kilograms (154 pounds), and he 

(xv) 



xvi INTRODUCTION. 

should therefore have about half as much food as the 
man. This disproportion in the needs of the infant as 
compared with the adult, is even greater than that of the 
child compared with the adult. By exact measurements 
it has been determined that an infant from its fourth to 
the sixth month consumes about twice as much food per 
kilogram body weight as the adult. 



PART I. 
General Considerations. 



CHAPTER I. 

THE ANATOMY OF THE DIGESTIVE TRACT 
OF THE INFANT. 

Oral Cavity. The salivary glands are well developed 
at birth, and the active principles of the salivary secre- 
tion are present, but in small quantities. Teething begins 
at about the sixth month, and dentition is not completed 
until about the end of the second year. In most instances 
this is a normal physiological process, and should cause 
no disturbances. However, in a considerable number of 
cases the gastric and intestinal secretions are affected re- 
flexly, with a diminished activity on the part of these 
glands ; and if there is any tendency to a general disturb- 
ance during this period, a reduction in the quantity of the 
food administered is indicated. However, far too great 
an importance is usually given by the laity to the process 
of teething. 

Stomach. In the newborn the stomach has a more 
vertical position than in the adult. However, rontgen- 
ologic examination has demonstrated that it is less ver- 
tical than has been formerly supposed. The cardiac end 
is found at the left of the tenth dorsal vertebra. The 
pylorus lies about midway between the ensiform cartilage 
and the umbilicus. The position of the stomach and its 
form, due to lack of development of the fundus and lack 
of muscular development at the cardiac end, account in 
great part for the frequency of vomiting in the infant. 

The pylorus also lacks the muscular development of 
the adult, and is decidedly more patent. 

(1) 



2 INFANT FEEDING. 

Considerable difficulty is experienced in our attempts 
to gain accurate knowledge of the capacity of the stom- 
ach. Pfaundler, who measured the size of the stomach 
in numerous infants, using air under a given pressure, has 
given us figures which are, in all probability, fairly ac- 
curate. 

He states that the capacity at birth is 2 ounces (60 
mils), at one month 2 to 3 ounces (60 to 90 mils), at six 
months 6 ounces (180 mils), and at one year 9 to 10 
ounces (270 to 300 mils). The importance of the stom- 
ach's capacity in determining the size of the individual 
feeding is only relative, dependent to a great extent upon 
the form of diet. With milk as the food, a considerable 
portion of the water content passes through the pylorus 
before the meal is finished, if the food is not too rapidly 
given. When a child is fed by gavage, the size of the 
meal is of greater importance because of the danger of 
overdistention by the rapid administration of the food by 
this method. Notwithstanding the fact that the size of 
the stomach varies in different babies, we have found it a 
good working rule with normal infants to administer at 
each feeding a quantity 2 ounces more of the liquid food 
than the infant is months old. 

The intestines are relatively larger than in the adult, 
which applies more especially to the large intestine, and 
particularly to the sigmoid flexure. The sigmoid is also 
more mobile, due to the greater length of the mesosig- 
moid, and is extra-pelvic. The musculature is rela- 
tively thin, and bears an important relationship to the 
frequency of intestinal distention and the presence of colic, 
which is due to the stagnation of large quantities of gas 
in the intestinal tract. 

The pancreas shows no special anatomical differences. 

The liver is relatively two-and-a-half times as large 
at birth as in the adult, and is easily palpable, and in the 
nipple-line of the right side usually extends 1 to 1^ 
inches (2 to 4 cm.) below the costal border. 



CHAPTER II. 

THE PHYSIOLOGY OF THE DIGESTIVE 
TRACT OF THE INFANT. 

While all the ferments are present in early life, they 
vary quantitatively and qualitatively as compared with 
older children. 

Mouth. Ptyalin, which is an amylolytic ferment, is 
present in the saliva immediately after birth, but is small 
in amount, and weak in its action. Albumin, water and 
mucus in saliva vary with the variety of food taken 
(Pavlow). 

Stomach. Gastric juice is present in the stomach 
even in the premature. Its secretion is mainly stimu- 
lated by the act of sucking and by the presence of the 
food in the stomach. 

Free hydrochloric acid is little less than in the adult. 
It may be stated that the small protein content of human 
milk, as compared with cow's milk, favors the presence 
of hydrochloric acid. This is a point of great importance 
in the food problem of the infant. Free hydrochloric 
acid is found in 10 per cent, of cases after 1 hour, and in 
33 per cent, of cases after 1^ hours on feeding with 
human milk (Hamburger and Sperck). With cow's 
milk, free hydrochloric acid is found very rarely, which 
is due to combination of the hydrochloric acid with salts 
and proteins. Total acidity is in small part only due to 
free hydrochloric acid. More important are phosphoric 
acid, acid phosphates, acid chlorides, fatty acids and acid 
albumins (albumoses and peptones). Total acidity is 20 
to 60 mils N :10 acid to 100 mils of gastric contents. The 
action of the hydrochloric acid is as follows: (1) it 
makes protein digestion possible (acid albumins) ; (2) 

(3) 



4 INFANT FEEDING. 

stimulates the pancreas; (3) disinfects and exerts anti- 
toxic action. 

The following ferments are present in the stomach : 
(1) Pepsin, which is present at birth, and is active and 
causes at least partial digestion of proteins. It increases 
to the fourth month, then remains fairly constant. More 
pepsin is present in bottle-fed infants. (2) Rennin is 
also present at birth, and in the presence of hydrochloric 
acid coagulates milk. Whether this is dependent on pep- 
sin, or whether it is a specific ferment, is a question. 
(3) Lipase, a fat-splitting ferment, is found in the stom- 
ach in small quantities, and is probably a definite product 
of the gastric mucosa. 

Small Intestines. Mucous membrane of the small 
intestines secretes about 1 liter of juice daily, and this 
contains all ferments at birth, they being, however, rela- 
tively feeble at first. The following ferments are pres- 
ent in the intestinal secretion: (1) erepsin (Cohnheim), 
which splits casein, albumoses, and peptones to peptids 
and amino-acids. Other albuminous bodies are not 
affected by it. (2) lactase, maltase, invertin; they split 
disaccharides (milk, malt, and cane sugar) to monosac- 
charides, and each is stimulated by its own sugar. (3) 
prosecretin, which is changed to secretin by hydrochloric 
acid from the stomach, and stimulates the secretion of 
the pancreas. (4) enterokinase, which activates the pro- 
teolytic enzyme of the pancreatic juice; and probably (5) 
diastase. 

Pancreas. All of the ferments (trypsin, steapsin, 
and amylopsin) are found in the intestines at birth. 

The liver possesses the ability to form glycogen and 
urea in the newborn. Bile is present, its emptying from 
the gall-bladder being stimulated by chemical action of 
fats on the duodenal mucous membrane. The functions 
of the bile are: (1) to hold fatty acids and fatty acid 
salts in solution, (2) to stimulate the pancreas, and (3) 



PHYSIOLOGY OF THE DIGESTIVE TRACT. 



an antiseptic action. Other functions of the liver are 
formation of urea, and formation and storing of 
glycogen. 

Large intestines secrete no enzymes, their chief 
function being absorption of water and throwing off of 
Ca, P, Na, K, Fe, Mg. 



CHAPTER III. 
METABOLISM IN INFANTS. 

1. General Considerations. 

The term metabolism covers all of the functions of 
the human body which have to do with the preparation 
for and assimilation of food. 

To furnish the body with fuel for its normal activities, 
the following groups of food elements are necessary: 
proteins, fats, carbohydrates, salts, and water. Fats and 
carbohydrates, and to a lesser extent proteins, furnish 
fuel; while the proteins and salts more especially form 
the elements necessary for body growth. 

It is necessary to distinguish between the activities 
which take place within the gastro-intestinal tract before 
absorption of the changed products and the deeper seated 
metabolism which takes place beyond the intestinal wall, 
which can be designated as the "intermediary me- 
tabolism." 

Under normal conditions in the adults the intake and 
the products of excretion balance one another, while in 
the infant there is a positive balance — that is, less is ex- 
creted than is absorbed — and one may well say that a 
balance which would be normal in the adult is patho- 
logical in the child, and would thereupon soon result in 
a stationary weight, or a loss in weight. 

Several factors offer difficulties in the study of infant 
metabolism. 

First, it is difficult to obtain stools free from urine and 
with the water content intact. 

Secondly, the small volume in which the urine and 
stools are obtained offers many difficulties in their study. 

Urine and stool examinations should cover a period of 
at least three days to be of conclusive value. 

(6) 



METABOLISM IN INFANTS. 7 

2. Composition of Milk and the Metabolism 
of Its Constituents. 

The natural food of the infant is human milk, char- 
acterized by the fact that its quality changes very little, 
the infant's growth being dependent on the increase in 
amount of milk secreted. 

Milk of different animals varies as to its fuel value, 
and also in its chemical composition, especially quan- 
titatively there being marked differences. 

Protein Fat Sugar Salts 

Human 1.5 3.5 6 to 7 0.20 per cent. 

Cow's 3.4 3.8 4 to 5 075 " " 

Human colostrum differs from the mature human milk 
in that the protein and salts are higher. Protein aver- 
aging 2.25 per cent., and the average ash 0.3077. Sugar 
not differing greatly from that the later milk, but aver- 
aging somewhat lower. Fats are also somewhat lower, 
averaging 3.15 per cent. (Holt 1 ). These figures vary 
in different women, and also with the day of puerperium, 
but represent average specimens. Colostrum also con- 
tains numerous leucocytes, and large cells containing fat. 
these latter probably being epithelial in origin. 

1. Proteins. Chemistry of Proteins. Proteins con- 
tain carbon, hydrogen, nitrogen, oxygen, sulphur, and 
phosphorus. They are highly complex chemical sub- 
stances, similar in their chemical composition to proto- 
plasm and essential to life. 

Of the proteins milk contains mainly casein and al- 
bumins, with small amounts of globulins, opalisin, 
nuclein, etc. 

100 mils of milk contain Albumin Casein 

Human milk 0.6 Gm. 0.8 Gm. 

Cow's milk 0.2 to 0.3 Gm. 2.7 to 3.0 Gm. 

Casein belongs to the nucleo-albumin group (proteins), 
which contain phosphorus, are insoluble in water, mod- 



Amer. J. Dis. Child., Vol. X, p. 228, October, 1915. 



8 INFANT FEEDING. 

erately in alkalies, precipitated by acids, not coagulated 
by boiling, and by pepsin digestion changed to para- or 
pseudo- nucleins (which are bodies rich in phosphorus). 
Chemically it is composed of a complex group of amino- 
acids, the basis of all protein bodies, and a prosthetic 
group which contains the phosphorus. Amino-acids are 
characterized by the group COOH, in which an H is re- 
placed by NH 2 group, e.g., acetic acid (CH 2 HCOOH), 
amino-acetic acid, or glykokoll (CH 2 NH 2 COOH). 

Human casein contains much less phosphorus than 
cow's (0.25 to 0.88). This proves that the casein of the 
human and the casein of the cow's milk are different 
bodies, although this difference is probably of a quanti- 
tative nature only. The two caseins differ also in their 
coagulability, the human casein being more difficult to 
precipitate with acids, salts and rennin. The soluble 
albumins are coagulated by heat and weak acids. 

Metabolism of Proteins. Casein is separated from the 
so-called whey albumin, and is changed to an insoluble 
paranuclein. It is unknown whether or not the enzyme 
causing it is identical with the protein digestive ferment 
secreted by the gastric mucous membrane. 

Pepsin (from the pyloric mucous membrane) changes 
paranucleus to albumoses and peptones, which then pass 
into the small intestines. (Erepsin, the ferment of the 
intestinal juices, works very rapidly on the end products 
of pepsin digestion.) In the small intestine an intricate 
splitting takes place. 

With the human milk as a food, a very small amount 
of nitrogenous products of the food appears in the stools, 
the total being about one-sixth of the intake, and part of 
this arises from 

1. Intestinal juices, 

2. Intestinal epithelium. 

3. Bacterial activity. 

After passing through the intestinal wall, proteins have 
three functions to perform : 



METABOLISM IN INFANTS. 9 

1. To replace used proteins (lost through urine, sweat, 
digestive juices, cell destruction, etc.). 

2. To satisfy cell growth which would be impossible 
without proteins. 

3. To furnish fuel for part of the dynamic loss (fats 
and carbohydrates are the natural fuels, the protein com- 
bustion being of secondary importance). 

In the average feeding with cow's milk, three times as 
much protein is given as needed for 1 and 2, therefore 
it is used for 3, (that is, dynamic purpose), or is rejected 
by the body. 

The great disproportion as seen in a comparison of 
the proteins in cow's milk over human milk is probably 
due to the needs for cell growth in the calf. Due to the 
ability of the organism, within certain limits to regulate 
its function, the excess of protein in the average diet 
with cow's milk as a basis is excreted by way of the 
intestinal tract. Cell growth is therefore not excessively 
stimulated on these relatively high protein diets. 

End Products of Protein Metabolism in Urine: 
Urea 60 to 80 per cent. Ammonia 3 to 10 per cent. 
Oxaluric bodies ^ 

. . > Nitrogenous by-products. 

Kreatimn ( a J 

Oxybutyric acid ' 

Urea forms 75 to 86 per cent, of the nitrogen con- 
stituents of the urine. 
By ammonia coefficient is meant the relation of am- 
monia to the other nitrogenous bodies in the urine. 
Influence of the Carbohydrates and Fats on the Nitro- 
gen Metabolism. 

1. Carbohydrates cause 

(1) Increased retention of proteins. 

(2) Increased nitrogen in feces. 

2. Fats cause 

(1) No increased protein retention. 

(2) Increased nitrogen in feces. 



10 INFANT FEEDING. 

2. Fats. Chemistry of Fats. Human milk fats are 
esters of palmitic, stearic, and oleic acids with glycerin, 
the oleic acid ester being present in larger amount in 
human than in the cow's milk. Human milk fats are de- 
rived partly from body fat and partly from food fat. 
Carbohydrates also furnish ingredients for fat making; 
proteins do not. 

Metabolism of Fats. 

1. Lipase from the gastric mucous membrane causes 
some splitting of fat. 

2. Fats are emulsified in small intestines. 

3. Live intestinal cells can change fatty acids to fats. 

Resorption. 

1. Lymph-vessels. 

2. Blood-vessels. 

Disposition. 

1. Subcutaneous tissue. 

2. Preperitoneal spaces. 

3. Liver. 

4. Burned with resulting end products. 

(1) Carbonic acid. (2) Water. 

In stools found normally as unresorbed portion of in- 
gested fat in the form of 

1. Fat (neutral). 2. Lecithin. 3. Cholesterin. 

4. Fatty acids representing 1 to 10 per cent, of fat 

ingested. 

5. Alkali soaps. 6. Earthy alkali soaps. 

In Urine. Fatty acids and glycerin are found in very 
small quantities, but we cannot say that these are from 
the fats ingested. 

Nursing babies always have at least a small amount of 
fat in their stools. In contradistinction to proteins, the 
fats in the stools are in greater part only unresorbed fats, 
only a small amount being due to cell activity. (Proteins 
greater part). 



METABOLISM IN INFANTS. H 

Various percentages of fat ingredients found by 
Klotz in 1 examination of breast milk stools are as follows : 

Neutral fat 29.5 per cent. 

Fatty acids 10.7 " " 

Combined fatty acids .... 58.8 " " (18.3 Ca and Mg.) 

While under normal conditions 18.3 per cent, of the 
fats in the stools exist as non absorbable fat soaps in 
the so-called fat soap stools, they will approximate 50 
per cent, of calcium and magnesium soap. 

Fat in the G astro-intestinal Tract and its Relation to 
Metabolism. Unlike proteins we can nourish the in- 
dividual without fats, as carbohydrates can replace them. 
If too long continued, the organism changes, however, in 
its chemistry through increased absorption of salts and 
water. 

3. Carbohydrates. Milk sugar formed by the mam- 
mary glands from material circulating in the blood is a 
disaccharide (glucose and galactose). 

Chemistry of Carbohydrates. 

1. Monosaccharides. 

(1) Glucose (dextrose, grape sugar). 

(2) Lsevulose (fruit sugar). 

They ferment and are reducible. (1) Has 
a right and (2) left polarization. 

2. Disaccharides. 

(1) Lactose — glucose and galactose. 

(2) Maltose — glucose and glucose. 

(3) Saccharose— glucose and lsevulose. 
(1) and (2) are reducible, (3) is not. 

3. Polysaccharides (three or more sugar molecules). 

(1) Flour. 

(2) Dextrin. 

(3) Cellulose. 



1 Langstein-Meycr : Wiesbaden, Vcrlag von J. F. Bergmann. 
Third edition, p. 16. 



12 ' INFANT FEEDING. 

Metabolism of Carbohydrates. Monosaccharides are 
without further change absorbed in the small intestine 
or fermented. 

Disaccharides are first reduced to monosaccharides by 
the intestinal ferments (every disaccharide having its 
specific ferment) before they can be absorbed. (This is 
not entirely true of maltose). 

Polysaccharides are first acted upon by ptyaline in the 
saliva ; this is continued in the stomach until the stomach 
content becomes acid, and then by enzymes of intestines 
and pancreas they are converted to monosaccharides. 

After absorption into the blood, the carbohydrates 
serve the following purposes : 

1. Used for energy. 

2. Synthetically inverted into glycogen. 

3. Fat foundation (probably). 

Body cells can oxidize only monosaccharides (maltose 
excepted). 

Interesting is the storing up of glycogen by the liver 
and muscles so that the sugar in the blood can be kept 
constantly at about 0.1 per cent. 

Glycogen is most easily made from glucose and lsevu- 
lose ; less so from galactose, maltose and starch ; least 
easily from cane and milk sugar. 1 - 

Fat is formed from sugar by the subcutaneous cells, 
which are especially adapted to this function. 2 

Sugar is oxidized to carbon dioxide and water, which 
can be measured by the respiratory metabolism. Nor- 
mally, sugar is absorbed from the small intestines, and 
is not found in the feces. 

Sugar appears in the urine when the capacity for 
assimilation is passed, thereby producing an alimentary 
glycosuria. This is most easily accomplished in the 



1 Otto von Furth: Physiological and Pathological Chemistry 
of Metabolism. J. B. Lippincott Company, p. 227-230. 

2 Langstein and Meyer : J. F. Bergmann, Wiesbaden, 1914, Third 
Edition, p. 16. 



METABOLISM IN INFANTS. 13 

following order: lactose, galactose, laevulose, glucose. 
The cane sugar limit is about the same as milk sugar, 
while that of malt sugar is 7.7 grams per kilogram body 
weight. The assimilation limit for sugars is much 
greater in infants than in adults. An infant may develop 
mellituria when milk sugar exceeds 3.1 to 3.6 grams 
per kilogram body weight; in the adult at over 1 gram 
per kilogram. The height of the assimilation limit in 
itself shows that the infant's organism is adapted to a 
higher carbohydrate metabolism than that of the adult. 

Carbohydrates in the Tissues. The newborn has a gly- 
cogen reserve which helps to sustain it until the appear- 
ance of the mother's milk. 

Carbohydrates can, in part at least, replace proteins 
and fats. They cause a rapid increase in weight (very 
rapid at first), being deposited in the tissues, as glycogen, 
which latter can absorb two to three times its weight of 
water. 

The relation of fats to carbohydrates is as follows: 

The more carbohydrates present, the greater is the ten- 
dency on the part of the system to build up body fats. 
As to oxidation of fats, "They are burned up in the fire 
of carbohydrates" (Naunyns). 

The complete burning of fats into carbon dioxide and 
water takes place only when the carbohydrate metabolism 
is normal; otherwise we get as mid-products the acetone 
bodies (acetone, aceto-acetic acid, oxybutyric acid, etc.). 

They occur most frequently in infancy and childhood 
following periods of underfeeding or starvation. (Im- 
portant in infants' disease, as seen during weaning, 
anorexia, continued fevers, intoxication, etc.) 

Acetone bodies can also be formed from protein mole- 
cules. This occurs in starvation and in excessive meat 
and fat diets (deficiency of carbohydrates in the latter). 

Weight becomes stationary or a loss results when car- 
bohydrates are excluded or insufficient in the diet. Tern- 



14 INFANT FEEDING. 

perature falls, and does not rise to normal until they are 
replaced. 

4. Salts. Chemistry of Salts. Salts added to water 
are relatively split into their "ions" — that is, into either 
electrically positive or negative bodies. A solution of 
sodium chloride is a solution in which the NaCl molecule 
is intact, but the Na (kation) is electro-positive; the CI 
(anion) is electrically negative. 

Mature human milk contains 0.2 Gm. ash in 100 mils. 
Cow's milk 0.75 Gm. ash in 100 mils. Some exists as 
inorganic salts, others as important organic compounds. 

I. Rations (or cations), 

1. Calcium. 

(1) Human 0.458 Gm. per 1000 mils, cow's 1.72 

Gm. per 1000 mils, about 1 : 4. 

(2) Excretion is almost entirely through intes- 

tines, some from unabsorbed food rem- 
nants, and the rest by tissue metabolism. 

2. Magnesium. 

(1) Human 0.074 Gm. per 1000 mils, cow's 

0.2 Gm. per 1000 mils. 

(2) Its metabolism is very closely related to the 

calcium. 

3. Sodium. 4. Potassium. 

(1) Human milk 0.132 Gm. Na 2 0, cow's 0.465 

Gm. Na 2 per 1000 mils, 1 : 3. 

(2) Human milk 0.609 Gm. KoO, cow's 1.885 

Gm. K 2 per 1000 mils, 1 : 3. 

(3) Excretion mostly through kidneys and 

stools. 
5. Iron. 

Human milk 0.0017 Gm. cow's 0.0007 Gm. per 
1000 mils. These figures show consid- 
erable variation according to different 
authors. Excreted mainly through the 
bowels. 



METABOLISM IN INFANTS. 15 

II. Anions. 

1. Chlorine. 

Human 0.358 Gm., cow's 0.82 Gm. per 1000 
mils, 1 : 3. 

(1) Absorption: 90 to 100 per cent, through 

the intestine. 

(2) Excretion: mostly through kidneys. 

(3) About 0.5 per cent, retained by the system. 

2. Phosphorus is contained in the milk in the fol- 

lowing forms : 

(1) Inorganic (calcium phosphate). 

(2) Organic (casein, nuclein, lecithin, etc.). 

(3) Total in human 0.345 to 0.418 Gm., in cow's 

2.437 Gm. per 1000 mils, 1 : 9. 

(4) Organic in human 43.3 per cent., and cow's 

46 per cent, 1:1. 

(5) The retention is higher in artificially fed 

than those fed on human milk. 

Relation of Salts to Metabolism. The salts are neces- 
sary in digestion and in every step of metabolism from 
absorption to excretion and secretion. The role of these 
salts in both normal and pathological conditions has been 
given constantly increasing importance in the last few 
years. 

Metabolism of Salts in Infants. In the gastrointes- 
tinal tract the foods and salts are constantly changing 
action. 

A casein product and calcium combine in the stomach 
to form calcium paracasein. 

Fatty acids and alkalies and earthy alkalies in the intes- 
tines form soaps. 

Casein increases excretion of salt in the intestine 
(moderate). 

Fat increases excretion of salts in the intestines 
markedly, (especially Ca, Na, K). At the same time the 
phosphorus excretion decreases as the calcium phosphates 
are changed to calcium soaps by combination of calcium 



16 INFANT FEEDING. 

with fatty acids, and the free phosphoric acid unites with 
sodium and potassium to form easily absorbed salts. 

Salts are excreted in the urine and stools. The stools 
are the main channel of excretion of calcium, magnesium, 
and iron. Whether these are formed from the tissues or 
unabsorbed food is difficult to decide. The difference in 
percentages in human and cow's milk is equalized by the 
body using only what is necessary to its life and growth 
and not attempting to use it all. 

functions of Salts. 

( 1 ) They furnish building material for new cells. 

(Rachitis due to lack of absorption.) 

(2) They are necessary to nerve excitability, muscle 

contraction, and many other vital functions. 

(3) Addition of calcium and potassium to normal 

salt solutions counteracts their poisonous 
effects. 

(4) Life is incompatible with withdrawal of min- 

erals or even one ion. 

(5) Life does not so much depend upon the ion as 

on its chemical combination. Therefore ash 
alone will not supply the needs. 

(6) Infants need minerals for growth, as well as 

for life. Different tissues require different 
amounts and different salts. 

(7) Weight drops with withdrawal of salts, even 

if other ingredients are constant, due to loss 
of water. Sodium salts are most important 
in water retention, calcium salts are least. 

(8) Temperature falls, when salts are withdrawn 

(sodium). 

(9) Phagocytosis is increased by calcium salts. Of 

value in infection. 

5. Water. Infants need 105 Gm. of water, and adults 
40 Gm. of water, per Kg. 

Metabolism of Water. Intake is in the food. The 
outgo from the kidneys, bowels, lungs, and skin. 



METABOLISM IN INFANTS. U 

Water when ingested quickly passes through the stom- 
ach to be absorbed by the intestines. The water content 
of the organism varies with age and food. In the adult 
58 per cent, of body is water, and in the newborn infant's 
body 66 to 69 per cent, is water. Sodium salts have the 
greatest facility for water retention. 

Of the anions, CI is the most marked in causing water 
retention. 

Excretion of water takes place as follows : kidneys 59 
per cent., skin and lungs 33 per cent., intestines 6 per 
cent. One to 2 per cent, of the water intake is retained. 

Relation of Water to Metabolism. Approximately 
two-thirds of the infant's body is water. All cells need it ; 
it is necessary to different combinations and reactions. In 
general, it is necessary for young infants on artificial 
feeding to receive about 140 to 150 mils (4 to 5 ounces) 
per kilogram (2 pounds) body weight every twenty-four 
hours. It carries nutritious material in the blood, lymph, 
cells, etc., and also the material for anabolism and kata- 
bolic products. It is also necessary to the function of the 
lungs and of the skin. Immunity to infection is to a 
large extent dependent on the water content of the body. 

6. Lipoids. Proteins and lipoids form the principal 
component parts of all living cells. The lipoids are a 
group of organic nitrogenous substances comprising the 
phosphatids, cerebrosids and cholesterin. The phospha- 
tids contain phosphorus, an organic base, and a fatty 
acid radicle in their molecule. The members of this 
series are lecithin, cephalin and cuorin. They are widely 
distributed in both animal and vegetable cells, but are 
especially abundant in the yolk of eggs, fish roe, brain 
tissue, yeast, blood and bile. They are also found to 
a lesser extent in cereal grains, legumes and beet root. 
The cerebrosids are isolated almost entirely from brain 
and nerve tissue. These do not contain phosphorus and 
yield galactose upon hydrolysis with dilute mineral acids. 
Cholesterin is an unsaturated secondary alcohol, is uni- 

2 



18 INFANT FEEDING. 

versally present in animal and vegetable tissue, and is 
most abundant in bile, yolk of eggs, nerve tissue and 
wool fat, and found abundantly in wheat, barley, beans, 
peas, lentils, carrots, peanuts and beets. 

Lecithin. Lecithin is the fatty acid ester of the glycero- 
phosphates (glycerin phosphoric acid), Human milk, 
0.499 Gm. per 1000 Gm. ; cow's, 0.63 Gm. per 1000 Gm. 

Cholestcrin. Human milk, 0.25 to 0.38 Gm. per 1000 
Gm. Mainly excreted by the intestines. 

This is of interest when we consider that fat-free milk 
contains but little lipoids. 

7. Vitamines. The term is used to cover a group of 
substances the chemical nature of which has as yet not 
been determined. These compounds are absolutely es- 
sential in food, in order to maintain the weight of the 
body and produce growth. The lack of sufficient vita- 
mines causes deficiency diseases, so named because they 
are due to a lack of something in the diet. It is unknown 
whether they exert their action directly on the tissues or 
indirectly, as has been suggested, through a hormone ac- 
tion. They cannot be produced by the animal organisms 
or are produced in such limited amounts that they are 
insufficient to meet the body needs. For this reason we 
are dependent upon the supply contained in the diet for 
these essential factors. 

Lower forms of animal life, such as yeast cells, seem 
able to elaborate vitamines, and plant cells possess this 
faculty to a high degree. It is also impossible for the 
body to store them to any extent. Therefore it is neces- 
sary that the food contain a constant supply. 

Tentatively they are grouped according to their solu- 
bility in fat and water and it may be hoped that a more 
scientific terminology will soon be applied to them when 
their chemical nature is better understood. At present 
they are described : 

1. Fat-soluble A vitamine (growth promoting). 



METABOLISM IN INFANTS. 19 

2. Water-soluble B vitamine (growth promoting 

and anti-neuritic). 

3. Water-soluble C vitamine (anti-scorbutic). 

The Fat-soluble A vitamine is thirty times as soluble 
in fat as in water. It is found in cod-liver oil, egg-yolk, 
butter, cream and milk. Because of tbe greater solubility 
in fats it is about equally distributed between the cream 
and the fat-free portion of the milk. It is contained in 
beef and mutton fat but little or none is found in lard 
and the commercial vegetable oils. It is found in con- 
siderable quantities in the heart, kidneys, liver and the 
glandular organs. The leaves of plants are rich in it, 
while the seeds and root vegetables contain less. 

The Water-soluble B vitamine is one of the essentials 
in the promotion of growth. It is found in yeast, fruit 
juices, vegetables and grain embryos. The leafy vege- 
tables and those growing above the ground, such as to- 
matoes and celery contain it in larger proportions than 
the root vegetables, such as potatoes, carrots, and turnips. 
It is also present in milk and egg-yolk. When cereals 
are very highly milled in order to obtain a very fine 
white flour, a large part of the vitamines may be re- 
moved. Vitamines are also lost when rice is polished in 
order to remove the outer layers, which contain most of 
the vitamines. 

The Water-soluble C vitamine is known as anti-scor- 
butic vitamine. It is found in oranges, grapefruit, lem- 
ons and other citrus fruits (these contain both B and C), 
and in green vegetables such as tomatoes, spinach, lettuce 
and cabbage, and in eggs and raw milk. It is present 
in actively living cells, so that in general those vegetable 
tissues which contain relatively large numbers of actively 
respiring cells (leafy vegetables), are richer in anti- 
scorbutic power than are the roots or tubers. This gen- 
eralization is not without exception. Different vegetables 
and fruits vary greatly in their anti-scorbutic potency. 
They differ widely also in the extent to which their anti- 



20 



INFANT FEEDING. 



scorbutic value will deteriorate under certain physical 
and chemical conditions (drying, alkalinizing, etc.). 
From the above statement it is apparent that the anti- 
scorbutic potency of foodstuffs varies directly with the 
quantity contained. 

For further facts on vitamines see Nutritional Dis- 
turbances due to Insufficient Vitamines, page 215, and 
Scurvy, page 364. 



Classes of Foodstuff 


Fat-soluble A 
or Anti- 
rachitic 
Factor 


Water-Solu- 
ble B or Anti- Antiscor- 
neuritic (An- butic 
tiberiberi) Factor 
Factor 


Fats and Oils: 


+ + + 
+ + 
+ + + 
+ + 
+ + 
+ 
+ + 

Value in pro- 
portion to 
amount of 
animal fat 
contained 

+ 

+ 

+ + 
+ + 


+ 

+ + 
4- 








Cod-liver oil 

Mutton fat 

Beef fat or suet 

Peanut oil 

Fish oil, whale oil, etc. ... 

Margarin prepared from 

animal fat 




Meat, Fish, etc.: 
Lean meat (beef, mutton, 


+ 
+ 






Heart 


+ + + 
+ + + 
+ 












very slight, if 
any 




Fish, fat (salmon, herring, 


+ + 






any 
+ + + 








Milk, Cheese, etc.; 
Milk, cow's whole, raw 


+ + 


+ 


+ 








Milk, boiled, whole 

Milk, condensed, sweetened 
Cheese, whole milk 

Eggs: 


undetermined + 
+ + 

+ 

+ + + + + 
+ + + + + 

+ + 

+ + 


less than + 
less than + 

? 




•> 


Cereals, Pulses, etc.: 
Wheat, maize, rice, whole 

















METABOLISM IN INFANTS. 



21 



Classes of Foodstuff 


Fat-soluble A 
or Anti- 
rachitic 
Factor 


! Water-Solu- 
ble B or Anti- 
neuritic (An- 
tiberiberi) 
Factor 


Antiscor- 
butic 
Factor 


Cereals, Pulses, etc.: 
(continued) . 




+ + 
+ + 
+ + 

+ + 

+ + 

+ 
+ 

+ 




Linseed, millet 


+ + 




Soy beans, haricot beans . . 
Germinated pulses or cer- 


+ 
+ • 

+ + 


+ + 

+ + + 

+ 
very slight 
very slight 

+ + + 


Vegetables and Fruits: 
Cabbage, fresh (raw) 




+ 




Swede (rutabaga) raw ex- 






+ + 
+ + 
+ 
very slight 


+ 

+ 
+ 








+ 




Beetroot, raw, expressed 


+ 




+ 


+ 




+ 

+ + 
+ at least 

+ + + 

+ + 

+ + 
very slight 

+ + + 

+ + 

+ 
very slight 

+ + 


Beans, fresh, scarlet run- 
























































+ 


+ 






+ 


+ + 

+ + + 
+ + + 
+ in some 
specimens 


Miscellaneous : 




Yeast, extract and autolysed 
Malt extract 








None of the three factors were found in: 

Lard. 

Olive, cottonseed, coconut or linseed oils. 

Coco butter. 

Hardened fats, animal or vegetable in origin. 

Margarin from vegetable fats or lard. 

Cheese from skim milk. 

Polished rice, white wheaten flour, pure cornflour, etc. 

Custard powders, egg substitutes, prepared from cereal products. 

Pcaflour (kilned). 

Meat extract. 

Beer. 



Report published by a Committee appointed jointly by the Lister In- 
stitute and the Medical Research Committee. 



22 INFANT FEEDING. 

3. Milk Digestion. 

1. In the Mouth. In the mouth milk is mixed with 
saliva, each 100 mils of milk averaging about 5 mils of 
saliva (Tobler). The secretion of saliva is stimulated 
mainly by the act of sucking, but also in part by appetite 
(psychic reflex). Ptyalin begins its action on the carbo- 
hydrates of the milk. Saliva may also cause coagulation. 

2. In the Stomach. In the stomach the milk is 
curdled, casein being precipitated by rennin. Human 
milk coagulates less rapidly and less completely than 
cow's milk. Therefore in the latter the curds and the 
whey are more quickly separated. 

Proteins are changed to albumoses and peptones by 
pepsin, and thus they are prepared for further digestion 
in the intestine. Albuminous digestive products stimu- 
late gastric secretion. 

Of fats 25 per cent, are changed to fatty acids and 
glycerin by lipase and action of bacteria. Fats at first 
retard, and later increase, the gastric secretion. 

Action of ptyalin on Carboliydratcs is continued for a 
time in the fundic end of the stomach. 

Absorption in the stomach is as follows: (1) salts and 
sugars, (2) proteins (small amounts), (3) water (none), 
(4) fats (none). 

Shortly after beginning of the nursing some of the 
whey content of the food begins to leave the stomach. 
This is more especially true if the ferments are active. 
The time also varies with the quality of the meals. 
Human milk leaves the stomach in about one and one- 
half to two hours after ingestion, and cow's milk in about 
three hours after ingestion. Two factors have an impor- 
tant bearing on this point: (1) the quantity of the fat, 
which delays the passage of the food through the pylorus, 
(2) the size of the curds, the large curds of the cow's 
milk delaying emptying of the stomach. 






METABOLISM IN INFANTS. 23 

As previously stated, whey quickly passes out of the 
stomach, and remaining curd is digested at its surface, 
and thus passes over. Solid masses may pass through. 
After each passage of food the pylorus again closes. The 
rapidity of emptying the stomach depends on the action 
of the pylorus, and this in turn on the chemical composi- 
tion of the food. Fats and albumins remain long in the 
stomach, sugars and salts passing through more rapidly. 

3. In the Small Intestines. The action of the gastric 
digestion on the proteins is supplemented by trypsin from 
the pancreas, and the erepsin of the succus entericus. 
End products of the protein digestion are amino-acids. 
Carbohydrates are split into monosaccharides in the 
small intestines and are absorbed there. Fats which have 
been split into fatty acids and glycerin are emulsified and 
absorbed. Absorption of all digested food is almost 
complete in small intestines. It may be stated that intes- 
tinal or pancreatic digestion is far more important than 
gastric digestion in the infant. 

4. In the Large Intestines. Absorption of water and 
excretion of salts are the chief functions of the large 
intestines in the digestive process. 

5. Feces and Urine. Feces is composed of food rem- 
nants, products of secretory activity of the intestines, 
desquamated mucosa of the intestines, and bacteria. 
Composition of feces depends to a certain extent upon the 
nature of the food ingested. Foods rich in proteins 
(skim milk, albumin milk, etc.) cause increased intes- 
tinal secretion, with resulting alkaline reaction, which 
favors putrefaction and furnishes conditions favorable 
for development of fat soap stools. Excess of carbohy- 
drates with acid fermentation gives another picture. 
Putrefaction and fermentation work antagonistically on 
the reaction of the stool. There is a balance between the 
acids derived from fat and sugars by bacterial action and 
the alkaline intestinal secretion. 



24 INFANT FEEDING. 

Proteins in the stool (giving biuret and Millon's tests) 
are in greater part not derived from food proteins, but 
they are due to intestinal secretions, desquamated epi- 
thelial cells of the intestines, and to the bodies of bac- 
teria. This is especially true of breast-fed infants. The 
normal infant stool contains no unchanged casein. 

Fat has an important influence upon the formation of 
the stool. On feeding with human milk poor in fat the 
stools are small, containing small quantities of solids and 
some mucus. On feeding with human milk which is rich 
in fat, normal stools are produced. Microscopically fat is 
always evident in stools, and is derived partly from food, 
and in small quantities from the secretion of intestinal 
juices. Fatty acids and fat soaps are constantly found. 

Salt excretion is an important function of the large 
intestine. In the breast fed, ash content of dry stool is 
10 per cent., bottle fed 40 per cent. Insoluble calcium 
salts harden the feces. 

The following are some tests on constituents of feces : 

1. Fat soap easily seen, as fatty acid crystals (needles) 
by heating with acetic acid on the cover glass and allow- 
ing to cool. 

2. Carbofuchsin in weak solution stains as follows : 
Neutral fat: no stain. Soaps: faint rose color. Fatty 
acids : red. 

3. Sudan III stains as follows: Neutral fat: orange 
red. Soaps : crystals do not stain. Fatty acids : stain 
red or crystals, orange red. 

4. Sugar is not demonstrable in any quantity as such, 
but the character of the fat soap stool seen in milk feed- 
ing without sugar is changed to a softer, smaller, and 
normal color by adding sugar. 

5. Starch is demonstrable by iodine test microscopic- 
ally, but care must be exercised in the interpretation of 
the test, as the starch may be derived from baby powders. 

The color of the stool is due to bile coloring matter de- 
rivatives: bilirubin and its reduction products, urobilin 



METABOLISM IN INFANTS. 25 

and urobilinogen. The less the bile pigments are reduced, 
the more colored the stools. By marked reduction to 
urobilinogen, the color becomes almost white. The more 
milk and cream, i.e., fat, in the diet, the paler the feces. 
The so-called soap stool is due to excess of fat and over- 
feeding with milk or cream with insufficient sugar, and 
is a firm grayish, putty-like stool. 

Thin watery stools must always be taken seriously. 
However, the same cannot be always said of green, curdy 
stools, which are not infrequently seen in thriving breast- 
fed infants. These curds are almost invariably due to 
fatty acids and soaps. 

Normal stools of breast-fed infants are homogeneous, 
salve-like, ochre-yellow color, acid, and of sour odor. 
Microscopically may be seen detritus masses, bacteria, 
few neutral fat corpuscles, and fatty acid crystals. 

Normal stools of bottle-fed infants vary with the diet. 
One can frequently tell the diet by the appearance of the 
stool. On milk diet: less frequent, usually 1 or 2 daily, 
firmer and drier, usually pale yellow, alkaline and of foul 
odor. Constipation is the rule in babies receiving large 
quantities of milk with a moderate amount of carbohy- 
drates. Sugars have a laxative tendency (fermentation). 
Excess of brown color may be caused by excesses of 
malt sugar. Starches, if well taken, tend to constipate, 
in large amounts they tend toward an acid reaction and 
an aromatic odor. 

Starvation or hunger stool is seen on a very limited 
diet, as minimum amounts of milk, tea, cereal water. 
The stool has a dark, greenish-brown color, is soft, and 
composed in great part of mucus, and appears semi-trans- 
parent. This mucus may lead to further starvation 
through mistaken interpretation of its meaning, and re- 
sult disastrously. 

In the past it was taught that a study of the stools gave 
one definite information for the differential diagnosis of 
the gastro-intestinal diseases, but experience has taught us 



26 INFANT FEEDING. 

that conclusions are of value only when based upon stool 
examinations in conjunction with a careful study of the 
diet, and clinical examination of the infant. 

Urine. A normal infant urinates ten to fifteen times 
daily, and the urine passed represents 60 to 70 per cent, 
of the fluids taken as food and drink. It is acid in re- 
action, and should be free from albumin. However, al- 
bumin frequently is present in the simple nutritional dis- 
turbances, and almost constantly in severe acute illnesses. 
Temporary presence of albumin in the urine of the new- 
born may be considered physiological, as well as the uric 
acid during the very early stage. Great decreases, even 
to anuria, are common with the intestinal disturbances. 



CHAPTER IV. 

BACTERIA OF THE DIGESTIVE TRACT 
OF THE INFANT.* 

1. The Newborn. 

For about one day the meconium passed by the new- 
born baby is sterile. During this time, however, the bac- 
teria begin to invade the digestive canal of the infant 
through the mouth and through the anus. The initial in- 
testinal flora which thus develops is subject to marked 
differences, the number and nature of the bacteria de- 
pending chiefly upon the surroundings of the infant, and 
exhibits no characteristic constant findings. 

This period is followed by gradual transition in the 
nature and in the number of the intestinal bacteria, until 
about the third day after birth characteristic intestinal 
flora become established, consisting chiefly of Bacillus 
bifidus (in tbe nursing infant) and Bacillus coli (in the 
artificially fed infant), and, besides these, Bacillus acido- 
philus, Micrococcus ovalis, Bacillus lactis aerogenes and 
others. 

2. The Nursing Infant. 

The principal portal of entry of the intestinal bacteria 
is the mouth. There is no doubt that a great variety of 
organisms may from time to time enter this atrium, in- 
cluding not only the ordinary organisms of the nursling's 
environments, but pathogenic bacteria as well. A major- 
ity of these pass to the stomach, and they may pass to the 
intestinal tract. 



* In the elaboration of this chapter free use has been made of 
A. I. Kendall's Bacteriology, Lea & Febiger, Philadelphia and 
New York, 1916. 

(27) 



28 INFANT FEEDING. 

The flora of the mouth and of the stomach are not 
well known, but they appear to be of relatively slight 
importance as a rule. 

The duodenal flora in health is composed chiefly of 
coccal forms of the Micrococcus ovalis type. Bacillus coli 
and other members of the colon group are most numer- 
ous at the ileocecal valve and the cecum, and Bacillus 
bifidus or similar organisms dominate the large intes- 
tines from this level to the sigmoid flexure. The re- 
mainder of the large intestines to the rectum is some- 
what sparsely populated with living bacteria, partly be- 
cause the fecal mass is relatively desiccated by the ab- 
sorption of water, partly because of the accumulation of 
waste products of bacterial activity — principally acids re- 
sulting from fermentation of lactose, formed higher up 
in the tract — which inhibit the development of bacteria 
in the lower levels. 

Bacillus bifidus (Gram positive, blue stain) predomi- 
nates in the intestinal flora of the breast-fed infant, being 
acid tolerant and finding favorable conditions for its 
growth and development, since in digestion of mother's 
milk lactic acid production from lactose is so great as to 
inhibit the growth of the Bacillus coli and Bacillus lactis 
aerogenes in the lower end of the ileum, while the highly 
acid medium favors the growth of the Bacillus bifidus 
communis and the acidophile bacteria. Coccal forms and 
lactose fermenting organisms are present, but scanty ; 
spore bearers are rare. 

3. Artificially Fed Infants. 
Escherich directed attention to the striking dissimilar- 
ity between the intestinal flora of the breast fed and the 
artificially fed infant. Culturally, morphologically, and 
chemically the former is more uniform than the latter. 
The most distinctive features of the dejecta of the arti- 
ficially fed infants are : the relative increase of Gram- 
negative bacteria of the coli-aerogenes type, and of coccal 



BACTERIA OF THE DIGESTIVE TRACT. 29 

forms of the Micrococcus ovalis type, together with a 
diminution of Bacillus bifidus. Bacillus acidophilus is 
relatively more numerous, as a rule, in the artificially 
fed infant than in the nursling. Proteolytic bacteria of 
several types are also of frequent occurrence, but they 
are not commonly found in the dejecta of the normal 
nursling. These organisms are frequently spore-form- . 
ing bacilli, of which two principal groups are recognized 
— members of the aerobic group, of which Bacillus mesen- 
tericus is a prominent type, and anaerobic bacteria, of 
which Bacillus aerogenes capsulatus is most widely 
known; it frequently occurs in small numbers in the 
feces of artificially fed infants. The reaction of normal 
feces of artificially fed babies is usually alkaline ; cul- 
turally and chemically, the evidence of intestinal proteo- 
lysis of bacterial causation is more marked in these in- 
fants than in normal nurslings. 

The general distribution of types of bacteria at the 
different levels of the intestinal tract is similar to that 
observed in normal nurslings. The principal differences 
are found in the cecum and large intestine, where the 
obligately fermentative bacteria of the bifidus type are 
replaced to a considerable degree by an extension of« the 
habitat of the Bacillus coli, of Bacillus acidophilus, and 
the appearance of moderate numbers of proteolytic bac- 
teria, both aerobic and anaerobic; many of the latter are 
sporogenic. 

The characteristic feature of the normal adult fecal 
flora as compared with the infantile nursling flora is the 
very heterogeneous variety of types of bacteria in the 
former, in sharp contrast to the homogeneity of types of 
bacteria in the latter. 

4. Significance of the Intestinal Bacteria. 
The striking differences in morphology, chemistry, and 
in cultural characters between the intestinal floras char- 
acteristic respectively of nurslings, artificially fed infants 



30 INFANT FEEDING. 

and adults suggest at once that nutritional stimuli may be 
an important factor in determining the dominance of 
type of bacteria. It is probable that the significance of 
the intestinal flora lies rather in its potential antagonism 
to alien bacteria, which certainly gain entrance to the 
alimentary canal from time to time, than in any specific 
participation in the normal digestive process of the 
host. The normal intestinal flora may be regarded as intes- 
tinal parasites, just as the various bacteria which occur 
commonly on the skin are regarded as cutaneous para- 
sites. It is important to realize that the normal intestinal 
organisms, like the cutaneous organisms, are "oppor- 
tunists," potentially capable of becoming invasive when- 
ever the barriers which ordinarily suffice to limit their 
development to the lumen of the alimentary canal become 
impaired, giving rise to endogenous infections. 

5. Influence of the Diet on the Intestinal Flora. 

Intestinal flora vary greatly, the most important fac- 
tor in determining its nature being the chemical composi- 
tion of the food. Human milk gives essentially different 
flora from cow's milk. There are two groups of bacteria 
possessing an antagonistic action, those causing fermen- 
tation (saccharolytic), and those causing putrefaction 
(proteolytic). The representatives of the former are Bac- 
illus lactis aerogenes and Bacillus bifidus, the latter being 
the most important organism in the stool of the breast-fed 
infants. The group exercising proteolytic activity is less 
clear. We know only that in the processes of putrefac- 
tion the bifidus flora is replaced by the coli group. De- 
pending on the predominating group of bacteria, putre- 
faction or fermentation takes place, causing either firm 
or soft stools, this rather than the activity of the ferments 
determining the nature of the stools. The nature of the 
food and its chemical composition, therefore, determines 
the nature, of the development and activity of the par- 
ticular bacteria in the intestinal tract. 



BACTERIA OF THE DIGESTIVE TRACT. 31 

The human milk, rich in sugar and low in protein, leads 
to the flora of fermentation, while cow's milk, rich in 
protein and poor in sugar, to the flora of putrefaction. 
This phenomenon is nothing specific, but is due to in- 
dividual components of the milk and their mixture. 

Carbohydrates lead to the development of the fermen- 
tative organisms ; the split products of carbohydrates are 
acetic, butyric, lactic and carbonic acids. 

The nature of the dominant organisms which develop 
in diets rich in carbohydrates varies with the carbohy- 
drate itself. Bacillus bifidus is more commonly predom- 
inant when lactose is the sugar fed, without an excess of 
protein. If maltose or dextrose is substituted for lactose 
under the same conditions, Bacillus acidophilus is very 
frequently the more prominent. 

The fermentative action is increased by sodium and 
potassium salts as found in whey. (This latter probably 
in part explains the results obtained in feeding malt 
sugars together with potassium carbonate.) 

Proteins favor the development of the organisms of 
putrefaction and lead to formation of indol, skatol, and 
amino-acids, these being the products of aromatic and 
fatty series. Gases are also formed by the latter action. 

The nature of the protein influences the types of pro- 
teolytic bacteria to a very marked degree. In general, 
animal proteins other than casein appear to encourage 
somewhat more active proteolytic flora than vegetable 
proteins. The processes of putrefaction are favored by 
calcium salts. 

The influence of fat in its relation to bacterial proc- 
esses is not clear. It seems to be able to favor fermenta- 
tion, if this be already present, and also to increase the 
intensity of the processes of putrefaction. 

In breast feeding fermentation outweighs putrefaction. 
The question whether fermentation or putrefaction in 
the intestinal canal is desirable, must be answered a priori 
that the fermentative processes are physiological, since 



32 INFANT FEEDING. 

breast feeding always leads to this. By this it must not 
be understood that the putrefaction in artificial feeding 
causes injury. Excessive intestinal fermentation in ar- 
tificial feeding may be the forerunner of disaster, and is 
to be avoided (dyspepsia, intoxication). 

Within certain limits, we are able to influence the bac- 
terial processes in the intestinal tract in the normal infant, 
and thereby change the character of the feces. In a sick 
infant this is more difficult, and larger quantities of 
putrefacient food are necessary to overcome pathological 
fermentation. 

6. Intestinal Bacteria in Their Relation to Gastro- 
intestinal Disturbances. 

There are many intestinal disturbances of unknown 
causation, presumably unrelated to bacterial activity. 
There is a second group of conditions in which bacteria 
may conceivably play a secondary part; in some of the 
latter abnormal physiological conditions in the alimentary 
canal may be justly regarded as the antecedent factors. 
The boundaries of these two groups are poorly circum- 
scribed, and they merge through imperceptible or poorly 
defined limits .into a third group of cases in which the 
activities of endogenous or exogenous bacteria in the 
alimentary canal may be the causative factor in morbid 
processes of the gastro-intestinal tract. 

The symptomatology induced from the products aris- 
ing from the decomposition of proteins or protein deriva- 
tives by the action of bacteria in the intestinal tract de- 
pends largely upon the organism or organisms concerned. 
It varies from the somewhat insidious, slowly progress- 
ing, so-called autointoxication, in which a marked in- 
crease of urinary ethereal sulphates may be a suggestive 
index, to the acute toxemias characteristic of bacillary 
dysentery, typhoid, paratyphoid or cholera. Of course, 
a variety of other bacteria than the few mentioned speci- 
fically may be concerned, either alone or in symbiosis. 






BACTERIA OF THE DIGESTIVE TRACT. 33 

Thus streptococci alone, and streptococci in association 
with dysentery bacilli, may be justly regarded as the etiol- 
ogical agents in their respective syndromes. The im- 
portant factor, from the viewpoint of this discussion, is 
to realize that the formation of nitrogenous products 
from proteins or protein derivatives, which are being 
utilized by various types of intestinal bacteria for 
energy, may be injurious to the host. 

The other prominent type of abnormal bacterial activ- 
ity in the alimentary canal — the fermentative type — is of 
entirely different origin. The essential factor is either 
a fermentation of carbohydrates, with the formation of 
products abnormal for the intestine, or of excess of nor- 
mal fermentative products. The factors leading to an 
overgrowth of these organisms in the intestinal tract 
appear to be an excess of carbohydrate and a lack of 
normal lactic-acid-forming bacteria. 

It is unfortunate that practically none of the bacteria 
which incite intestinal disturbances or illnesses produce 
soluble toxins against which antitoxins can be prepared. 
Sera likewise have been unsatisfactory. There is little, 
therefore, that can be accomplished serologically with the 
present methods in the treatment of intestinal disturb- 
ances of bacterial causation. Attempts to permanently 
eliminate or destroy undesirable bacteria with cathartics 
and intestinal antiseptics have not been productive of re- 
sults in the past, and prolonged starvation per se does not 
lead, to intestinal sterility or to a significant reduction in 
the offending bacteria. 

There are two ways, however, in which direct influ- 
ence may be applied to bacteria in the intestinal tract : 
by substituting harmless types of organisms for abnormal 
types, and so varying the diet for space that the intestinal 
contents at the desired level shall contain nutritive sub- 
stances that may be reasonably expected to shift the me- 
tabolism of the offending organism, and therefore radic- 
ally change the character of the products of its metabolism. 



34 INFANT FEEDING. 

Diseases Due to Proteolytic Activity of Bacteria. 
There are a number of conditions of bacterial causation 
in which available evidence points strongly to the forma- 
tion of products arising from the metabolism of protein 
or protein derivatives by specific organism as important 
etiological factors in the morbid process. Thus, cholera, 
bacillary dysentery, typhoid, paratyphoid, and many less 
acute infections are associated definitely with the de- 
velopment of these organisms within the body, and to 
some degree at least, at the expense of the body tissues. 

Available evidence points strongly to the view that 
cholera vibrios, typhoid, dysentery and paratyphoid bacilli 
and similar organisms produce their characteristic and 
harmful effects when they are developing in media free 
from utilizable carbohydrates; when utilizable carbohy- 
drates are added to these media, non-characteristic, harm- 
less products are formed. 

In the absence of any definite indication to the con- 
trary, it would be logical to attempt to maintain a suffi- 
cient concentration of carbohydrates within the intestinal 
canal in these infections as a therapeutic measure. 

The important effects to be accomplished by a liberal 
carbohydrate diet in those infections where the decom- 
position of proteins or protein derivatives by bacterial 
activity leads to chronic or acute illness of intestinal 
origin are : a change in the metabolism of the offending 
organism resulting in the formation of lactic and other 
acids in them in place of putrefactive products, and a 
gradual replacement of the proteolytic and pathogenic 
types by bacteria of the fermentative varieties. 

Diseases Due to Excessive Fermentation of Carbohy- 
drates. Another type of intestinal disturbances depends 
upon an unusual or an excessive fermentation of carbo- 
hydrates. This is frequently seen in young infants, in 
many of whom we have a limited carbohydrate tolerance. 
(See Nutritional Disturbances.) 



Part II. 

The Nursing. 



CHAPTER I. 

GENERAL CONSIDERATIONS. 

Writers on this subject are very prone to state that 
the ability of the mother, particularly among the well-to- 
do, to fulfil this most important function is decreasing. 
This may have been a true statement fifteen or twenty 
years ago. At the present time, however, we are sure it 
is erroneous. The young mother of to-day is better able 
to nurse her offspring than was her sister fifteen or 
twenty years ago. We attribute this to the fact that the 
youth of the present day are more vigorous, more nearly 
normal individuals, than were those of an earlier date. 
Breast-milk during the first two or three weeks of the 
infant's life is produced under unfavorable conditions, 
which do not indicate the possibilities of the breast as a 
secreting organ. Early nursing, following as it does 
upon the stress of confinement, is not indicative of what 
may be possible later, when the customary life and daily 
habits are resumed. Repeatedly we have found a very 
high fat or a high protein, or both, entirely corrected 
after the first week or two, without interference. This 
condition at the time was considered sufficiently serious 
to warrant the discontinuance of nursing on the part of 
a weakly infant, while in a vigorous infant it would be 
entirely ignored. A neurotic mother makes the poorest 
possible milk-producer. Proportionate to the popula- 
tion, there are fewer neurasthenics among the young 
women to-day than there were twenty years ago, and 

(35) 



36 INFANT FEEDING. 

there will be still fewer twenty years hence. At the 
present time the timid, retiring young woman of the 
neurasthenic type is not popular in her set. 

Few functions with which we have to deal are so 
variable and uncertain as the production of breast milk. 
Breast milk is one of the most precious substances. It 
is invaluable, unless we can put value on human life. 
The most successful nursing age is between the twentieth 
and thirty-fifth year. 

Some mothers will be able to carry on the nursing for 
only two months, others three, five, seven, or nine 
months. In our experience in both out-patient and in 
private practice it is extremely rare for the breast milk 
to be sufficient for the infant after the ninth month. 

It should be remembered that besides the protein, fat, 
carbohydrate, salts and water content there are other 
bodies contained in human milk, which, even though not 
essential to the infant's life, are of inestimable value 
to it. These may be divided into two groups: 

1. Immunizing bodies — antitoxins, alexins, etc. — 
which are contained in the mother's blood, and trans- 
mitted to the baby through her milk. They are of value 
in protecting the infant against infections. 

2. Ferments : lipase, galactase, lactokinase, and dias- 
tase. 

Examination of Human Milk. This is rarely of any 
practical value. The protein rarely causes trouble, and 
the sugar is usually constant (6 to 7 per cent.). The 
examination of milk is therefore usually restricted to a 
determination of the fat content by means of the lacto- 
meter. The richest milk, however, will usually agree 
with the baby, and it is apt to thrive equally well on a 
milk that shows a small amount of fat. In other words, 
the baby and not the lactometer is the only practical test. 
If the milk disagrees, it will be evident clinically. No 
baby should ever be deprived of its mother's milk only 



GENERAL CONSIDERATIONS. Z7 

because of the results of a clinical examination of the 
milk. 

In making an examination of the mother's milk one 
must bear in mind that the first milk is very poor, the 
last very rich in fat, and that an average specimen can 
be obtained only by mixing the whole amount, or by 
combining the first and the last, or, better still, by taking 
only the middle portion after a few drams have been 
drawn off. This can be accomplished by allowing the in- 
fant to nurse for two minutes before expressing the 
sample. 

Contraindications to Nursing. Tuberculosis when 
progressive or open is always a contraindication to nurs- 
ing, because of the danger to the infant and the strain on 
the mother. With proper precautions, and where the 
breast is not diseased, and human milk is not obtainable 
from other sources, it may be well to tide a weak infant 
over its first weeks by expressing the milk from the 
mother's breast. 

Syphilis of the mother, except in freedom from infec- 
tion on the part of the infant, is not a contraindication. 
Lack of symptoms on the part of the mother in congeni- 
tal syphilis is a very common occurrence ; a Wassermann 
reaction on the mother's blood will quickly clear up any 
doubt. 

Any grave constitutional disease in which there is an 
extraordinary drain on the resources of the body (dia- 
betes, heart disease with disturbed compensation, neph- 
ritis, Basedow's disease, malignant neoplasms, epilepsy 
and psychoses) are contraindications to nursing. 

Acute diseases should only in exceptional cases be con- 
sidered as contraindications to nursing, and should in- 
clude conditions in which there is danger of overburden- 
ing the mother and infections endangering the infant. 
(See p. 65 for further indications.) 



CHAPTER II. 

MATERNAL NURSING. 

1. Nursing Axioms. 

The following may be laid down as nursing axioms : 

A diet similar to what the mother was accustomed to 
before the advent of motherhood can usually be taken. 

There should be one bowel evacuation daily. 

From three to four hours daily should be spent in the 
open air in exercise which does not fatigue. 

At least eight hours out of every twenty-four should 
be given to sleep. 

There should be absolute regularity in nursing and 
expression. 

There should be no worry and no excitement. 

The mother should be temperate in all things. 

2. Hygiene of the Mother. 

The Diet of the Mother. Many times, when con- 
sulted by nursing mothers because the nursing was un- 
successful or a partial failure, we have found that their 
diet had been restricted to an extreme degree. To put 
on a greatly restricted diet a robust young mother who 
has always eaten bountifully of a generous variety of 
foods is one of the best means of curtailing the quantity 
and lowering the quality of her milk supply. When 
asked to prescribe a diet, we tell such mothers to eat as 
they were accustomed to before the advent of pregnancy 
and motherhood. That this particular vegetable or that 
particular fruit should be forbidden on general prin- 
ciples is a fallacy. Food that the patient can digest with- 
out inconvenience is a safe food so far as the nursing is 
concerned, as may readily be determined in any given 
case. For certain individuals, however, a plain, more or 
(38) 



MATERNAL NURSING. 39 

less restricted diet is desirable. This must be enforced in 
the management of the wet-nurse (to be detailed later). 

Nursing is a perfectly normal function, and a woman 
should be permitted to carry it out along the natural 
lines. Inasmuch as there are two lives to be provided 
for instead of one, more food, particularly of a liquid 
character, may be taken than the mother may be accus- 
tomed to. It is our custom to advise that milk be given 
freely. A glass of milk may be taken in the middle of 
the afternoon, and 8 ounces of milk with 8 ounces of 
oatmeal or cornmeal gruel at bedtime, if it does not dis- 
agree with the mother. Our only evidence that a food is 
disagreeing is the condition of the digestion. When 
any article of food disagrees with the mother, or if she 
is convinced that it disagrees, whether or not such be 
really the case, the food should be discontinued. In a 
general way, milk (one quart daily), eggs, meat, fish, 
poultry, cereals, fresh vegetables and fruits constitute a 
basis for selection. Although occasionally a nursing 
mother cannot take acid fruits, salads and aromatic vege- 
tables, they may be tried and discarded, if they disturb 
the infant. Eggnogs, thin cereal gruels mixed with milk, 
cocoa and malted milk and similar drinks can often be 
taken to advantage between meals. 

The Bowel Function. A very important and often 
neglected matter in relation to nursing is the condition 
of the bowels. There must be one free evacuation daily. 
For the treatment of constipation in nursing women we 
have used different methods in many cases. The dietetic 
treatment and plenty of recreation and exercise promise 
most. Manipulation of the diet should not be such as 
to interfere with the milk production. Three other 
methods are open to use: massage, local measures and 
drugs. Massage is available in comparatively few cases. 
Local measures consist in the use of enemas and sup- 
positories. Every nursing woman under our care is in- 
structed to use an enema at bedtime, if no evacuation of 



40 INFANT FEEDING. 

the bowels has taken place during the previous twenty- 
four hours. For a laxative in such cases and in many 
others, a capsule of the following composition has served 
well : 

B Extracti nucis vomicae 0.015 Gin. (% gr.). 

Extracti cascarse sagradse 0.325 Gra. (v gr.). 

Sig. : To be taken at bedtime. 

The amount of the cascara sagrada may be varied as 
the case may require. In not a few instances we have 
found it necessary to give 2 capsules a day in order to 
produce the desired result. Neither the nux vomica nor 
the cascara appears to have any appreciable effect on the 
child. 

Air and Exercise. Outdoor life and exercise are not 
only as desirable here as they are under all other con- 
ditions, but to the nursing woman, with her added re- 
sponsibility, they are doubly valuable. In order to get 
the best results, exercise or work should be so adjusted 
as not to reach the point of fatigue. The mother whose 
nights are disturbed should be given the benefit of a 
midday rest of an hour or two. It should be our duty, 
however, to explain to the mother and to other members 
of the family that an important element in satisfactory 
nursing is a tranquil mind. 

Care of the Breasts. A well established routine should 
be instituted for the care of the breasts. To facilitate 
this a readily accessible tray with the necessary utensils 
should be provided. This should contain a glass-stop- 
pered bottle with a saturated solution of boric acid, a 
jar of cotton pledgets on toothpicks, to be used as appli- 
cators for the boric acid, a graduated glass or beaker. 
The nipples should be thoroughly washed before and 
after nursing with a saturated solution of boric acid 
poured fresh from the bottle for each cleansing, and the 
surplus thrown away. The boric acid should be applied 
with the cotton pledgets. The fingers should not come 



MATERNAL NURSING. 41 

in contact with the nipples, if the child is to nurse directly 
at the breast. If the nipples are tender, they should be 
anointed with a sterile mixture of 5 per cent, tincture 
of benzoin in liquid vaseline. 

All utensils, including the breast-pump, if one is in 
use, should be sterilized by boiling. In case of the breast- 
pump, the rubber bulb may be removed for this purpose. 
Where the milk is to be expressed by hand, the hands 
must be thoroughly disinfected by washing with soap 
and water, and rinsing with alcohol before manipulation 
of the breasts. Under all conditions soap and water 
should be freely accessible, and their use required before 
handling the breast or the infant. 

3. Conditions Influencing the Breast Milk. 

The advent of the first menstruation period particu- 
larly, and in some cases the beginning of every men- 
struation period, is attended with an attack of colic or 
indigestion in the child. Such attacks, however, rarely 
necessitate the discontinuance of the nursing even for 
a single day. Not infrequently the quantity of milk is 
somewhat lessened during menstruation, and this will re- 
sult in the infant becoming fretful, due to insufficient 
quantity of the feeding. Under no circumstances should 
menstruation be considered an indication for weaning. 

Factors influencing the mental condition of the mother, 
such as anger, fright, worry, shock, distress, sorrow, or 
the witnessing of an accident may affect the milk secre- 
tion sufficiently to cause no little discomfort to the child, 
and oftentimes the lessening of the flow for a day or 
two. At times, especially when the mother is under in- 
fluence of shock or grief, it may be necessary to substi- 
tute artificial feeding for a few nursings during these 
periods, until the mother has again resumed her mental 
equilibrium, her breast being emptied by mechanical 
means in the meantime. 



42 INFANT FEEDING. 

Drugs, alkaloids of opium, hyoscyamus, belladonna, 
and similar drugs, when given in large quantities, not in- 
frequently pass into the milk, and should therefore never 
be administered in large quantities to the nursing mother. 
Belladonna may cause a decrease in milk secretion, and 
should be administered with caution during the period of 
lactation. Mercury, iodides and the newer salts of ar- 
senic are also secreted in the milk, and may be used to 
advantage when a luetic mother is nursing a luetic infant. 

4. The Nursing Proper. 

Regularity in Nursing. The breast which is emptied 
at definite intervals invariably functionates better than 
does one which is not, not only as regards the quantity, 
but also the quality, of the milk, thus regular habits in 
breast-feeding are as essential to milk production as to 
its digestion and assimilation. The baby should be 
wakened to be fed. 

The average mother will supply the needs of the in- 
dividual meal with one breast, and the breasts should be 
alternated in successive feedings. Thorough emptying 
of the breast should be encouraged under all circum- 
stances, as this is our best method for increasing the 
milk supply, and the baby is the only means at hand by 
which this can be accomplished. This should be en- 
couraged in every instance. It is most readily thwarted 
by allowing a lazy baby to partially empty both breasts, 
and will soon lead to a diminished milk secretion. By 
this means the mother and the baby soon become adapted 
to one another, and it will be found that the desired effect 
is accomplished both where the milk supply is insuffi- 
cient or, again, excessive. In the former instance com- 
plete emptying of the breasts increases the secretion, and, 
where excessive, incomplete emptying will soon result in 
a lessened supply. 

Sometimes, however, it is advisable to give both breasts 
at each feeding, i.e., under the following conditions : ( 1 ) 



MATERNAL NURSING. 43 

During the first few days, to stimulate secretion, and a 
little later to relieve the congested breasts; (2) to weak 
babies when there is an abundance of milk, and they are 
not strong enough to get the last milk that comes harder ; 
(3) to overfed babies, where it is desirable to give them 
only the first and weakest milk, and to lessen the yield 
of the milk from the breast; (4) as the milk supplied by 
one breast fails to meet the needs of the infant, both 
breasts should be given at each nursing; the first breast 
should be thoroughly emptied before alloAving the baby 
to take the second breast, and the next nursing started 
on the second breast given in the last feeding. 

Number of Feedings in Twenty-four Hours. Four- 
hour intervals at start with six feedings in twenty-four 
hours, five feedings by the second to the fifth month, ac- 
cording to the individual needs of the child. Night 
nursing can often be discontinued by this time, and 
babies properly fed will go from 10 p.m. to 6 a.m. with- 
out anything but perhaps a drink of water. 

Premature and delicate infants and infants with a 
tendency to vomit are exceptions, and must be fed smaller 
amounts at more frequent intervals. 

Length of Nursing. As a rule a robust baby takes 
three-fourths of the milk obtained from a good breast 
in the first live minutes of a twenty-minute nursing. 
Fifteen to twenty minutes should be the limit for the 
nursing period. 

The quantity received at individual nursings will vary 
greatly throughout the day. The early morning nursings 
will often yield twice the amount of the later nursings. 
Therefore it is necessary to ascertain the twenty-four 
hour quantity in order to estimate the total value of milk 
received. 

When one breast does not meet the infant's demands 
both breasts should be given at each feeding, the normal 
nursing time of fifteen or twenty minutes being divided 
between the two breasts, either equally or by alternating 



44 INFANT FEEDING. 

a long and short feeding period of fifteen and five min- 
utes, so that each breast will receive a long nursing period 
at alternate feedings. Weak and lazy babies may require 
awakening during the nursing period to keep them at 
work. Very weak babies may require a longer period 
with short intervals in which they rest. 

The Daily Total of Milk Required. Most young in- 
fants will satisfy their requirements for growth and de- 
velopment when receiving an average of two and one- 
half ounces (75 mils) of human milk per pound (y 2 
kilo.) body weight, in twenty-four hours. Roughly this 
may be stated as one-sixth of the body weight in milk 
daily (50 calories per pound). Older infants will usu- 
ally thrive on two ounces (60 mils) or 40 calories of 
breast milk per pound or one-eighth of their weight. 

While infants of the same weight and age under the 
same conditions will require practically the same amounts 
to provide for growth and development, on the whole the 
fat baby will require less per pound than the thin one. 

Water Requirements. When the infant is receiving 
one-sixth of its body weight in milk during the day, little, 
if any additional water is required. When the breast- 
milk does not meet this requirement additional water or 
other food must be administered to meet the required 
one-sixth of the body weight in fluids. During the first 
days of life, when the breast milk supply is insufficient, 
total fluids should be administered to meet the above 
needs. From one to three ounces of a 2 to 5 per cent, 
solution of cane or milk sugar which has been boiled, 
may be given to the infant at twenty- four hour intervals 
until the milk appears. 

Before giving the water, the infant should be placed 
at the breast at each feeding. Even when milk is plen- 
tiful the administration of water two or three times daily 
from a nursing bottle accustoms the infant to taking the 
food in this way. An infant so trained will meet emer- 



MATERNAL NURSING. 45 

gencies of weaning more readily than one unaccustomed 
to bottle feeding. 

Feeding During the First Days. During the first 
day of life, food may be withheld for twelve hours, the 
infant being kept in a warm crib. It usually soon falls 
asleep, and as a rule it should be awakened only to 
change diapers. As a rule the child does not evidence 
its initial sensation of hunger by crying until after its first 
half day of life, and even then in many cases it is dif- 
ficult to obtain the co-operation of the infant in adminis- 
tering its food. During the second twelve hours the 
infant may be put to the breast two or three times in 
order to stimulate secretion and to teach it to nurse. 
During the second twenty-four hours the baby should be 
put to the breast at regular four-hour intervals. The 
sixth feeding may be omitted. By the third or fourth 
day the infant will usually receive most of its required 
food from the breast. If a night feeding is to be insti- 
tuted it is well to waken the baby at the regular hour in 
order to cultivate regular habits, which are so essential 
to the mother's welfare. 

The Total Nursing Period. Some mothers will be 
able to carry on the nursing for only two or three months, 
others as long as nine months. In out-patients as well 
as in private practice, it is exceptional to find a breast- 
milk supply which is sufficient for the infant after the 
ninth month. It is usually wise to allow one bottle feed- 
ing daily, by the end of the third or fourth month, in 
order to relieve the mother, and at the same time train 
the baby in bottle feeding. 



CHAPTER III. 

WET-NURSING. 

1. The Wet-nurse: Her Selection and Her Baby. 

The Problem. When there is a positive inability on the 
part of the mother to nurse her offspring, either through 
inadequate functioning on the part of the breast or sys- 
temic disease, we are confronted with the problem of 
securing human milk from another source, as notwith- 
standing the numerous isolated reports on successful 
raising of infants on artificial foods, the statistics of in- 
fants fed by artificial foods when compared with those 
of infants fed on human milk are so strikingly in favor 
of the latter that the obtaining of human milk must al- 
ways be considered as an important issue. 

How Obtained. In our experience, even in a large 
city, great difficulty has been met in obtaining a regular 
supply of wet-nurses. On several occasions various 
charitable and hospital societies have attempted to estab- 
lish a wet-nurses' registry as a clearing-house for the 
several maternity and general hospitals of Chicago. 
These attempts have not been successful for two reasons : 
(1) because of the irregularity in the demand, and (2) 
because of the lack of co-operation on the part of the 
various institutions caring for this class of cases. 

The Nationality of the Wet-nurse is of considerable 
significance where the supply allows of a selection. The 
phlegmatic temperaments as seen in women of Northern 
and Central Europe of Teutonic and Slavic descent, 
offer the ideal material, while other nationalities, such as 
Italians, and the Southern negroes when removed from 
their home environment to a Northern climate, with the 
consequent change in diet, secrete a milk poor in quality. 
'(46) 



WET-NURSING. 47 

However, even the latter in an emergency should not be 
neglected. 

Requirements of a Good Wet-nurse. 1. She should 
be in good health, and, especially, free from all con- 
tagious and infectious diseases, and also from local 
diseases of any kind, such as those involving the nose, 
throat, skin, etc. 

2. Her mammary glands should be of such quality that 
she can secrete sufficient milk of good quality, and the 
nipples sufficiently developed to allow of nursing, or 
proper expression of the milk. 

3. Whenever possible, her age should be not less than 
18 and not more than 35 years. 

4. The age of her baby, as compared with that of the 
baby she is to nurse, is a matter of indifference in most 
instances. However, the first weeks, or if possible the 
first two months, of Jactation should be avoided, because 
of the presence of colostrum and the rapidly changing 
quality of the breast milk, which not infrequently causes 
serious gastric and intestinal disturbances in very suscep- 
tible infants, as evidenced by vomiting, colic and diar- 
rhea. Multiparity may be considered an asset, if the 
nurse has demonstrated her ability to care for and feed 
previous cases. A multipara is also less likely to be 
affected by her new surroundings, especially if this be a 
private home. When the wet-nurse has more or less 
direct charge of the infant, one who has been nursing 
her own or other infants will be more likely to meet the 
technical difficulties in the care of her charge. 

Examination of the Wet-nurse. The examination of 
the wet-nurse should always be made in a systematic 
manner to insure against overlooking important things. 

First, a careful history should be taken as to the num- 
ber of her children, miscarriages, and the presence of 
constitutional diseases in her family. 

Second, she should be thoroughly examined, all parts 
of the body being exposed, and the examination should 



48 INFANT FEEDING. 

include the skin and hairy parts of the body for the pres- 
ence of skin lesions and parasites, as well as for old 
luetic scars. The organs of the chest and abdomen 
should be subjected to careful examination. 

Third, the breasts should be examined. 

Fourth, the genitalia, including the cervix and the 
urethra, and in all cases a cervical (and where sus- 
picious, a urethral) smear should be taken and exam- 
ined for gonococci. As a single smear is often mislead- 
ing, in cases of the slightest suspicion, where a girl baby 
is to be nursed, the examination of the cervical and 
urethral smears should be repeated. 

Fifth, an examination and search should be made for 
chronic infections, especially for syphilis. A Wasser- 
mann test should be made in every case, and reported 
upon before she is allowed to supply milk, as it is well 
known that a syphilitic mother in a very great number of 
cases shows no clinical evidence of syphilis. The 
mouth and pharynx, neck, anus and genitalia, entire skin 
and lymphatic glands should also be examined for evi- 
dence of syphilitic lesions. 

Tuberculosis. The lungs, glands, and osseous system 
should be examined, and a careful history as to suscep- 
tibihty to colds and to recurring bronchitis elicited. 

Sixth. Acute infections. She should be questioned as 
to exposure to contagious disease, and she should be ex- 
amined for evidence of acute infections of the nose, 
throat, and ears. 

Seventh. Her teeth should be examined and defects 
and pyorrhea corrected, if necessary, at the expense of 
the family. 

Eighth. The urine should be examined (1) for evi- 
dence of nephritis, (2) for evidence of diabetes. It 
should, however, be remembered that a positive reaction 
for sugar should not be overestimated, unless the sugar 
is proven to be dextrose, as very commonly in our ex- 
perience during the early weeks of lactation a lactosuria 



WET-NURSING. 49 

is present. The kind of sugar can easily be determined 
by the phenylhydrazine test, followed by a microscopical 
examination of the crystals. 

Ninth. Nervous and psychic disturbances, such as 
epilepsy, insanity, hysteria, should be cause for rejection 
of the nurse. 

Tenth. Her child should be examined for evidence of 
syphilis. Possibly one of the best arguments for the 
non-employment of a wet-nurse during the first two 
months of her lactation is the possibility of a latent 
syphilis. Where there is the slightest doubt, a Wasser- 
mann reaction should be made on the infant. The gen- 
eral condition of the child gives us the best evidence both 
as to the quantity and to the quality of the maternal milk. 
Unless the source of the nurse be known, it is well 
to be certain that she is nursing her own baby. In case 
of its death or its absence, every effort should be 
made to obtain its condition at birth and its later 
development. 

So far as possible she should not be subjected to an- 
noying questioning on the part of the family, which is 
entirely unnecessary, if she has been properly examined 
by the physician. It has been our experience that such 
unnecessary questioning has led to nervousness, and not 
infrequently has caused her to decline the position, at a 
time when she was most needed. 

Her Place in the Household. She should be treated 
neither as a guest nor as a menial, but so far as possible 
should be graded according to her previous station in 
life. There is a grave danger of mental depression on the 
part of a woman, well-born and sensitive, who, through 
misfortune or necessity, is forced to seek this means of 
employment, and also of an exaggerated estimate of 
self-importance on the part of a woman but little accus- 
tomed to the luxuries of life upon her entrance into the 
home of employment, particularly if attentions are paid 
to her. As has been previously stated, all instructions 



50 INFANT FEEDING. 

and demands should be made by the person best qualified 
in the individual case. A divided responsibility will 
always lead to future complications. 

Her quarters should be well located ; their ventila- 
tion should be supervised, and she should be held re- 
sponsible for their general cleanliness. The wet-nurse's 
baby should always be kept in the room with her, so that 
she may feel the full responsibility for its health and care. 

The Quantity of Milk to be Expected from a Good 
Wet-nurse. The quantity and quality of milk supplied 
must vary greatly with the glandular development of the 
individual wet-nurse, the state of her health, and the 
factors quoted elsewhere which would affect it tempor- 
arily. The amount and variety of stimulation applied to 
the breasts, of which the direct nursing by a full-term 
infant is the most valuable (at least for the purpose of 
stripping the breasts), must be given due consideration. 
In view of the many emergencies and influencing factors, 
no absolute standard for quantity and quality can be set 
for general rule. 

A wet-nurse who does not secrete sufficient milk dur- 
ing the first few days in her new employment should not 
be discharged until every effort has been made to im- 
prove her milk production. Frequently the change in 
environment is sufficient to reduce it temporarily. 

Cost of Milk. The wet-nurses in Sarah Morris Hos- 
pital receive their board and room and $12.00 per week. 
Figuring the former at $10.00 per week, this would total 
a cost to the institution of $22.00 per week for each 
nurse. With an average of 30 to 40 ounces of milk per 
nurse daily, or 210 to 300 ounces per week, the average 
cost will be about 7 to 10 cents per ounce, or approxi- 
mately $2.25 to ^3.25 per quart. 

When milk is dispensed to patients outside of the hos- 
pital, a charge of 10 cents an ounce is made for it, which 
is a reasonable price when all of the contending factors 
are taken into consideration. 



WET-NURSING. 51 

Number of Nurses Needed. Each good wet-nurse 
can care for the needs of about two infants, depending 
upon their weight and development. In addition her own 
infant can often be satisfied with the strippings. When 
insufficient her baby may be given a mixed diet. 

Length of Lactation. No time-limit is placed upon 
the employment of a wet-nurse as long as the quality and 
quantity of her milk is sustained, and she continues in 
good health. One of our nurses had an infant eighteen 
months old. Such long periods of lactation, however, as 
a whole are not to be advised. 

The Wet-nurse's Baby. The presence of the wet- 
nurse's baby predisposes to her peace of mind, and 
wherever possible, she should take it with her. Her 
baby's state of health is by all means the best indication 
as to her ability as a nurse, and, with this, the presence 
of constitutional disease in herself. It may be of im- 
mense value, if the baby is strong and healthy, to keep 
up the flow of milk, in case the baby to be nursed is a 
weakling. It may also be used to estimate the functional 
capacity of a wet-nurse by nursing at regular intervals, 
and weighing before and after the nursing for twenty- 
four-hour periods. If in perfect health, it may be put to 
the breast, after the weakling has taken such milk as it 
has strength to draw. If this is not practicable, then the 
weakling should be nursed alternately with the well baby 
on each breast. It is also of immense value in emptying 
the breast after the wet-nurse has removed as much 
milk as it is possible by expression or by the breast- 
pump, if this is the means of drawing the milk for the 
weakling. It is a well-known fact in all institutions 
where wet-nurses are used, that the greater the degree 
to which the breasts are stimulated by suckling infants, 
the greater will be the reward in production. If the milk 
is insufficient for both babies, partial or entire meals of 
artificial food may be substituted for the wet-nurse's 
infant. 



52 INFANT FEEDING. 

At the first sign of an acute illness on the part of the 
wet-nurse's baby, it should be separated entirely from the 
other baby, and removed from the breast; its illness 
should be given the same serious consideration as that of 
the other infant, so that the mother's anxiety may be re- 
lieved. It should receive as much of its mother's milk 
as can be spared. This can be expressed from the 
breasts and fed from a bottle. 

Feeding of the Wet-nurse's Baby. When a single 
infant is to be nursed, the second baby is often a neces- 
sity in the promotion of the development and stimulation 
of her breasts. No breast can be developed to its fullest 
capacity with the breast-pump or hand expressions. It 
is a well-known fact that the breasts will respond in pro- 
portion to the demand placed upon them, and in most 
instances during the first few weeks of the premature's 
life, when its demands are met by from 4 to 16 ounces of 
milk, the wet-nurse can supply sufficient milk for both 
babies. When her supply becomes insufficient to meet 
the demands, her baby can be put upon partial bottle 
feedings of the strength as indicated by its age and de- 
velopment. The progress of the wet-nurse's baby has 
great influence on her peace of mind, which may spell 
success or failure in her ability to carry out her work. 
When the premature infant gives evidence of sufficient 
strength to be placed upon the breast, we have found the 
application of the wet-nurse's baby to the other breast a 
very valuable expedient in aiding the flow of milk into 
the breast which is to be nursed by the weakling. In 
many instances we have seen the milk flow from the 
second breast by this method so freely that but very little 
effort was required on the part of the weakling to obtain 
its food. 

2. The Hygiene of the Wet-nurse. 

In general, everything that has been said in the chap- 
ter on hygiene of the nursing mother applies also to the 



WET-NURSING. 53 

wet-nurse — of course, with the proper modifications, 
made necessary by peculiarities of her position. 

Her clothes should be simple, and in every part 
washable. As the care of her undergarments is of even 
greater importance than her outer clothing, it is well that 
her laundry should be done with the family work, so that 
the family laundress who is trusted by the family may be 
charged with its inspection. 

To simplify nursing or the drawing of milk, the 
author has devised two garments for wet-nurses. The 
material used for the outer garment is of yellow gingham, 
such as is used in the making of hospital uniforms, the 
yellow color being selected to distinguish the wet-nurse 
from the blue, as used by the nursing corps. The cor- 
set-waist is to be made of heavy muslin. The corset, if 
worn at all, should be of a very low type, so as to avoid 
all pressure on the breasts. It is best of a cheap quality, 
so that it can be replaced frequently for sanitary reasons. 
Each wet-nurse should be supplied with four uniforms 
and six nursing corset-waists. 

The Diet of the Wet-nurse. There is danger of the 
creation of indolent habits through neglect of regular 
exercise and the lack of regular household duties, but 
even greater danger lies in the direction of overfeeding 
with unusual foods. The average wet-nurse is either ob- 
tained from an institution or a home in which the lux- 
uries of life are limited, and she has been accustomed to 
a simple nutritious diet. Every attempt should be made 
to supply the nursing woman with a well-rounded diet 
of simple foods, with milk and cereals as the basis, and 
these supplemented with meats, soups, the common vege- 
tables, limited amounts of fruits and plain desserts. In 
so far as possible, the aromatic vegetables, unripe and 
highly acid fruits, fried meats, and rich pastries are to be 
avoided. We believe that, on the whole, too great stress 
has been laid upon the danger of the diet in the mother 
of a full-term infant, and in most cases the average 



54 INFANT FEEDING. 

mother can partake of a very full diet. However, in the 
case of the woman nursing premature infants, it should 
become a custom to allow only such foods during the 
first few days after her installation as can be given with 
perfect impunity. When a full, free flow of milk is 
established, other vegetables and fruits can be added, 
one at a time, and after each addition to the diet a try- 
out should be given the milk. We have on numerous 
occasions seen marked intestinal distention and diarrheal 
attacks following even seemingly slight indiscretions of 
the diet on the part of the wet-nurse. It is our hospital 
practice to furnish each wet-nurse with two quarts of 
good wholesome milk daily, and at least one pint of 
cereal gruel, preferably farina or corn-meal. A mixture 
of milk and cereal gruels makes a very good combination 
for drinking midway between meals. The remainder of 
the milk may be taken with the meals, either pure or in 
the form of cocoa, tea, or weak coffee, in whichever form 
it is best taken by the individual woman. The latter is of 
considerable importance, as in the forced diets which are 
required, where an abundance of milk is demanded, dis- 
tasteful foods soon become obnoxious in large quan- 
tities. 

Beers, malt-extracts, and other rich drinks are not 
forced upon the nurse, unless she is accustomed to them, 
and feels their need. It must always be remembered that 
an excess of fluids would naturally tend to dilute the 
milk unless the secreting gland be of exceptional develop- 
ment. 

Exercise of the Wet-nurse and Her Work. She 
should be impressed before her engagement with the fact 
that she will be required to do a moderate amount of 
work and exercise regularly out of doors. The former 
will be of service in promoting her general health, and 
both the work and the exercise will serve as a nerve tonic 
and prevent her becoming indolent. This does not mean 
that she should become a drudge, but that she should at 



WET-NURSING. 55 

least be required to care for her own room and her own 
infant's clothes, and should be made to feel that in re- 
turn for her laundry work she would be requested to do 
some light general work about the house. Her exercise 
in the open air should so far as possible be at regular 
times. The question as to the care of the napkins of both 
babies is open to considerable discussion; and it may be 
stated that whenever it becomes necessary for the nurse 
to express her milk by hand, she should not be subjected 
to the handling of soiled napkins, whenever this can be 
averted. 

Other Conditions Influencing the Quality 
of the Breast Milk. 

The nervous and mental state of the nurse is of the 
utmost importance, and wherever possible an emotional, 
nervous, erratic woman should be excluded, because of 
the tendency of these influences to suppress the flow of 
milk. Therefore, whenever possible, a woman of more 
or less phlegmatic temperament is to be selected. This 
is especially true in the case of a woman who is to be 
in close contact with and is to nurse an infant with neu- 
rotic tendencies. There is also the possibility of the same 
influence being manifest in time of slight indisposition 
on the part of her own infant, and such an individual is 
also more likely to resent the necessity of partial or en- 
tire artificial feeding of her own child to the advantage of 
the premature infant, when it has reached such an age 
when it may make greater demands on her supply. 

Menstruation rarely produces any serious disturb- 
ances. It is always a safe procedure to dilute the milk 
during the first and the second day of menstruation when 
the nurse suffers considerable pain at these times. 

Period of lactation may or may not be a considerable 
factor, depending upon the individual woman. We had 
in our employ a nurse who had been with the institution 
for sixteen and a half months, and whose infant was 



56 INFANT FEEDING. 

eighteen months old, and who supplied us with the largest 
quantity and the best quality of milk of the four nurses 
in the institution. 1 When possible a nurse should be 
selected after the first few weeks of lactation, at which 
time the colostrum has disappeared from the milk, and 
the quantity and quality of her milk has become estab- 
lished. After the first few weeks of lactation, but little 
or no attention is to be paid to the age of the wet-nurse's 
baby as compared with that of the infant to be fed, and 
we have never noted any ill effects following this rule. 

3. The Nursing. 

The Infant's Bedroom. Under ideal circumstances, 
this should be separated from that of the wet-nurse. 
This is especially true where a trained attendant has care 
of the infant. It should under all circumstances also be 
separated from the wet-nurse when she is of a low de- 
gree of intelligence and of a type not to be trusted with 
the care of the infant. 

Methods of Drawing Milk. Numerous methods of 
obtaining milk from the breasts have been described, but 
only those most practicable of application will be de- 
tailed. These should be divided, first, into those in which 
the baby is placed directly at the breast, and those meth- 
ods by which the milk is drawn from the breasts and fed 
to the infant. Two methods are especially applicable 

1 The milk of this nurse was examined in the laboratories of 
the University of Chicago after seventeen months of lactation 
with the following result : 

Albumin 1.30 per cent. 

Casein 0.69 

Fat 3.54 " " 

Lactose 7.025 " " 

Salts 0.1885 " " 

It must be remembered that this is an exceptional case, and but 
few women under the stress of ordinary life can properly nurse 
their infants after the ninth to twelfth month, 



CHAPTER IV. 
THE NURSING INFANT. 

Signs of Successful Nursing. The normal full-term 
infant shows a gain of not less than 4 ounces weekly. 
This is the minimum weekly gain which may safely be 
allowed. When a nursing baby remains stationary in 
weight or makes a gain of but 2 or 3 ounces a week, it 
means that something is wrong, and the defect will usu- 
ally, but not invariably, be found in the milk supply. 
When the baby is nursed at proper intervals, and the 
supply of milk is ample and of good quality, it is satis- 
fied at the completion of the nursing. Under three 
months of age it falls asleep after ten or twenty minutes 
at the breast. When nursing period again approaches, it 
becomes restless and unhappy, crying lustily if the nurs- 
ing be delayed. When the breast is offered, it takes it 
greedily. The weekly gain in weight under such condi- 
tions is usually from 4 to 8 ounces. At the fifth month 
the baby will have doubled, and at the twelfth month 
trebled its birth weight. The average gain per week dur- 
ing the first year is about 4 ounces. 

The baby increases in length from about 20.5 inches 
(50 cm.) to 28.5 inches (70 cm.) in the first year. The 
first tooth appears at about the sixth or seventh month, 
and at one year there should be six teeth or more. (Age 
in months, minus 6 = number of teeth normally present 
at that age.) It begins to smile at about the fifth week, 
grasps objects and holds its head erect in the fourth 
month, sits alone for a few minutes at seven or eight 
months, bears its weight on its feet at the ninth or tenth 
month, stands with slight assistance at the eleventh or 
twelfth month, and creeps or walks soon after this (tenth 
to eighteenth month, average fourteenth month), and 
says a few words towards the end of the first year. 

Stools. The feces of breast-fed babies are strikingly 
uniform, and are like no other bowel movement in in- 

(61) 



62 INFANT FEEDING. 

fancy. Normally, there are two or three a day, some 
times only one, or even more than three. They are soft, 
or mushy, homogeneous, of an egg-yellow or gold color, 
and have a slightly sour, not at all unpleasant odor. They 
are never formed, and always cling to the diaper. The 
nature of the bowel movement, and its uniformity, is 'due 
to the "physiological fecal flora" which is brought about 
by the ingestion of breast milk into the germ-laden in- 
testinal tract, and which in turn have a fermentative 
rather than a putrefactive action on the food. The gases 
normally formed are carbon dioxide and hydrogen, and 
these are practically odorless. The acidity of the move- 
ment, its softness, and the mechanical action of the gases 
present, all insure active peristalsis and ready emptying 
of the bowels, so that constipation is an exceptional con- 
dition in a breast-fed baby, and, if present, it nearly al- 
ways suggests too little food, or abdominal and intestinal 
muscles too little developed and too weak to force the 
stool past the anal sphincter. This latter condition is 
commonly interpreted as constipation by the laity. 

The dried residue of the feces contains from 10 to 30 
per cent, of fat, about 8 per cent, salts, a very large per- 
centage of bacteria, bile pigments, intestinal secretion 
(mucus, etc.), epithelial cells, etc. No food proteins or 
carbohydrates are found. 

The feces of the breast-fed baby are very frequently 
not wholly normal ; they quite commonly, especially dur- 
ing the first few months, contain small, soft, white or 
yellowish fat curds, an excess of mucus, and are often 
greenish in color, and may be more frequent than nor- 
mal. Such a condition is perfectly consistent with a nor- 
mal growth and well-being of the baby, and should never 
in itself be a cause of worry, or an indication for a 
change of food. This is a very important point that is 
very commonly neglected. The condition of the bowel 
movements is only one factor, and in the breast fed a 
minor one, in determining a baby's nutrition. 



CHAPTER V. 
MIXED FEEDING AND WEANING. 

Mixed Feeding (allaitement mixte). With a dimi- 
nution in the amount of milk secreted, the breast milk 
must, of course, be complemented or supplemented by 
modified cow's milk. These methods of feeding are usu- 
ally successful. By complemental feeding we mean the 
administration of milk from a bottle following a period at 
the breast at each nursing. By supplemental feeding sub- 
stitution of a bottle for a breast feeding is meant. Thus, 
in the former the baby receives as many part bottle as 
breast feedings, while in the latter it will be supplied with 
one or more bottle feedings to replace breast feedings. 
As we know that the breast secretes in proportion to its 
stimulation, the complementary feeding is far more satis- 
factory, and not infrequently it is wise to nurse both 
breasts for a short time, let us say, each one five to ten 
minutes, before the bottle is given. 

It is necessary to weigh the infant before and after 
nursings for one or more days to obtain a fair idea of 
the amount of cow's milk mixture that it will be neces- 
sary to administer in cases of underfeeding at the breast. 
Given a normal infant weighing ten pounds, the food 
value of twenty-five ounces of breast milk should be ap- 
proximated (% of his body weight). 

Clinical experience has taught us that most infants will 
thrive on artificial mixtures approximating the food val- 
ues contained in breast milk. Roughly, one and one-half 
ounces (45 mils) of cow's milk to which %o ounce (3 
grams) of sugar, cane or milk, and one ounce of water 
has been added, will meet the requirements for each 
pound body weight (% kilo). Such a mixture will con- 
tain F-2.4, P-2.1, C-6.7 per cent. 

(63) 



64 IXFAXT FEEDING. 

Example: A ten-pound infant receiving 15 ounces of 
breast milk is receiving two and one-half ounces for each 
six pounds of his body weight and will require in addi- 
tion the equivalent of two and one-half ounces for each 
of four pounds body weight which can be supplied by 
six ounces (one and one-half times four) of cow's milk 
and four-tenths of an ounce of sugar. 1 To meet his 
water requirements, the mixture should be made 10 
ounces, adding four ounces of boiled or cereal water. 

The cow's-milk mixture is best fed in part after each 
breast nursing. By giving both breasts at each feeding 
they receive the maximun amount of stimulating. The 
infant may be fed at three- or four-hour nursing periods. 

For the thin infant breast milk plus substitute feedings 
must approximate the requirements of his full weight for 
his age. 

In beginning the use of cow's milk, however, it must 
be remembered that at first a weaker strength must 
be used than the child will require for growth, this 
weaker food being necessary in order gradually to ac- 
custom the infant to the change. If too strong a cow's 
milk mixture is given at first, it will be very apt to 
disagree, causing colic and vomiting. Later, when the 
child has become accustomed to the new food, a stronger 
mixture may be given. When a mother cannot give 
her infant at least two satisfactory breast feedings 
daily, it is advisable to wean the child.. The new- 
born baby is not very discriminating, and will nurse 
anything equally well. The older baby, however, quickly 
prefers the easy-flowing bottle to the increasingly un- 
satisfactory breast, and will quite regularly stop nursing 
at the breast as the milk comes harder and is less abun- 
dant. If the bottle is given right after the breast, it is 
always well to use a nipple from which the milk comes 
with some difficulty, for the reasons given above. If it 



1 Cane sugar — two level tablespoonfuls equals one ounce. 
Milk sugar — three level tablespoonfuls equals one ounce. 



MIXED FEEDING AND WEANING. 65 

is desirable to wean the baby rather quickly, this method 
of following the breast by the bottle is often to be 
preferred to the other. 

Indications for Weaning. Pregnancy is usually an 
indication for weaning. The mother's milk becomes 
more scanty, and often poor in quality. This is especially 
the case if the mother knows she is pregnant, and has 
been taught that a pregnant woman should never nurse a 
baby. If the baby continues to thrive at the breast, there 
is no reason why nursing should not be prolonged. For- 
tunately a new pregnancy does not often supervene be- 
fore a time that makes it quite safe to wean the nursing 
baby, i.e., before the sixth month. 

In acute infections in the mother, such as pneumonia, 
and the acute contagious diseases, such as scarlet fever, 
one must weigh the danger from exposure to infection as 
against the quality of the artificial food and environ- 
ment in the individual case. 

In the milder contagious diseases, such as measles, 
mumps, it is true that young breast-fed infants are rarely 
infected. Pertussis is an exception, and has a high mor- 
tality in the newborn and young infants ; and the infant 
should under all circumstances be protected from ex- 
posure. In the presence of diphtheria the infant can be 
immunized with safety. 

Weaning should always be done gradually, when pos- 
sible, for the sake of both mother and the child. In 
cases of sudden weaning, the food must be very much 
weaker in the beginning than for an artificially fed child 
of the same age. If weaned at six months, the infant 
should be put on a mixture suitable for a child of two or 
three months, and the same rule applies for older infants. 
When the infant becomes accustomed to cow's milk, the 
strength can gradually be increased. Rarely should 
breast feeding be continued beyond the first year. 

The fear of the laity of the "second summer" is well 
founded when dirty milk and other improper foods are 

5 



66 INFANT FEEDING. 

fed promiscuously, but with clean, certified, and sterilized 
milk, and properly prepared soft foods, the dangers of 
the summer heat are minimized. It should be our rule 
to underfeed rather than overfeed in hot weather, and 
during the hot spells the infant's diet may well be re- 
duced one-half. 

Care of the Breasts During Weaning. When the 
breast feeding is carried on the usual length of time 
(from nine to twelve months), the process of weaning 
ordinarily causes little or no discomfort. All that is usu- 
ally required is to press out enough of the milk to re- 
lieve the patient as often as the breast becomes painful, 
which may not be more than two or three times a day. 
When the weaning is necessarily abrupt, no little dis- 
comfort may result. When the weaning can be accom- 
plished more gradually, the infant should have one less 
nursing every second or third day, until only two are 
given daily. After this has been practised for one week, 
nursing should be discontinued. In cases of sudden 
weaning, a saline laxative, such as citrate of magnesia or 
Rochelle salts, should be given every day for five days — 
sufficient to produce two or three watery evacuations 
daily. In the meantime the mother should abstain from 
fluids of all kinds up to the point of positive discomfort. 
The breasts should be elevated by a firm binder. 



CHAPTER VI. 

NUTRITIONAL DISTURBANCES IN THE 
BREAST-FED INFANT. 

Breast milk alone furnishes all of the needs for 
growth and development of the human offspring. The 
infant will thrive in most instances on breast milk from 
different sources and different quality, demonstrating the 
ability of the average infant to assimilate the food which 
Nature intended for its use, even though the percentage 
quantity of the various components may vary greatly. 
Disturbances in the breast-fed baby are dependent upon 
one or more of several factors. In the order of their fre- 
quency they may be divided, as follows. 

1. Underfeeding. 

2. Overfeeding. 

3. Congenital debility, with resulting impairment of 
the vital functions. 

4. Intercurrent parenteral (pharyngitis, tonsillitis, 
bronchitis, pneumonia, pyelitis, etc.) and enteral in- 
fections. 

5. Idiosyncrasy towards mother's milk. 

While all nutritional disturbances in young infants are 
of serious import, they are far less dangerous than those 
of the artificially fed infant, and much more easily cor- 
rected. They are also much less frequent than nutritional 
disturbances in artificially fed infants. 

1. Underfeeding. 

Etiology. Two factors of prime importance must 
be investigated to complete the diagnosis : 

( 1 ) The daily quantity of the milk furnished to the 

infant. 

(2) The quality of the milk supplied by the mother. 

(67) 



68 INFANT FEEDING. 

The milk may contain the normal percentage of fat, 
sugar, and protein, but be scanty in amount. Instead of 
the 4 or 5 ounces to which the child is entitled, it may 
get but 1 or 2 ounces. Whether or not the quantity is 
sufficient, may be determined by weighing the baby be- 
fore and after each nursing for twenty-four hours. 
(The ordinary spring balance infant scale will not 
answer, and a simple beam scale with weights and scoop 
should be supplied.) One ounce of breast milk weighs 
practically 1 ounce avoirdupois. By nursing for fifteen 
minutes, a child under one week old should gain 1 to 1.5 
ounces; at three weeks of age, 1.5 to 2 ounces; four to 
eight weeks of age, 2 to 3 ounces ; eight to sixteen weeks 
of age, 3 to 4 ounces ; sixteen to twenty-four weeks of 
age, 5 to 7 ounces; six to nine months of age, 6 to 8 
ounces ; nine to twelve months of age, 8 to 9 ounces. Of 
course, arbitrary limits cannot be fixed as to the quan- 
tity. It is not necessary to worry about the quantity 
taken at individual feedings so long as the infant is mak- 
ing satisfactory gains in weight, and the general progress 
is good. 

Quantity of Human Milk Required by the Nursing 
Baby. Babies of the same age and weight, under the same 
conditions, will take nearly the same amount of food. The 
older and larger the baby, the larger the total quantity of 
food required, but its energy quotient — that is, the num- 
ber of calories per kilogram or a pound of weight — lessens 
steadily with increasing age. The daily amount thst nor- 
mal, thriving babies take from the breast can be stated 
at about one-sixth to one-fifth of their body weight dur- 
ing the first month, about one-sixth to one-seventh up to 
Ihe sixth month, and about one-eighth after the sixth 
month. Heubner expressed this in terms of energy 
quotient, as follows : "During the first few months an 
infant requires 100 calories per kilogram daily of breast 
milk ; after the sixth month this energy quotient gradually 
comes down to 80 or 85 at the end of the first year. An 



NUTRITIONAL DISTURBANCES. 69 

energy quotient of 70 is about the minimum amount that 
an infant can take without losing weight." Human milk 
can be estimated at 21 calories per ounce, and about 70 
calories per 100 Gm. of milk. With these figures in 
mindj.it is easy to determine whether a breast-fed infant 
gets about the right amount of food, and we have also a 
valuable standard by which to measure the food of an 
artificially fed infant. 

Symptoms. Failure to gain weight properly, or even 
a loss in weight, may be the first positive evidence of an 
insufficient food supply. Usually this is associated with 
more or less evidence of dissatisfaction on the part of the 
infant. The infant's sleep becomes disturbed, and it 
becomes restless, and cries long before the next feeding 
time. Again, it may manifest its dissatisfaction by nurs- 
ing greedily for a short time, releasing the breast and 
crying. It returns to the breast again, but with the same 
result ; or in other instances the infant will remain at the 
breast for much longer periods than should be necessary 
to obtain the food that it needs, which should be accom- 
plished in from ten to twenty minutes. 

Usually the stools are normal in appearance, but small 
in amount, and give little evidence of the cause of the 
trouble. However, if the food supply be decidedly in- 
sufficient, we may have a positive evidence of the under- 
feeding by the appearance of the so-called "hunger 
stools," which are of more or less brownish or greenish- 
brown color, containing little fecal matter and much 
mucus. 

If the condition is not corrected, the baby becomes 
weak and apathetic, the skin loses its turgor, the tem- 
perature becomes subnormal, it is pale and anemic, the 
fontanelles become depressed, and the abdomen sunken. 
Whenever there is room for doubt as to the cause of this 
group of symptoms, the scale will be the most positive 
evidence. 



70 INFANT FEEDING. 

Treatment. Undue haste in removing the baby from 
the breast offers the greatest danger in the treatment of 
underfeeding, and should be resorted to only when other 
means fail. 

Mixed Feeding should be instituted when the breast 
milk supply is inadequate. (See page 63.) 

The ability to increase the quantity of milk secreted 
by the average woman must necessarily vary directly 
with the quantity and quality of the glandular tissue 
composing the breast. However, to a certain extent 
at least, certain factors will more or less directly in- 
fluence the quantity and quality of the secretion, and they 
are worthy of our attention. 

Means of Stimulating the Breasts. The surroundings 
of the mother must predispose to a happy frame of mind ; 
she must not be overburdened with household cares ; her 
exercise must be regular, and she must be relieved of 
worry and lack of sleep. It is well, if possible, to free 
her from all care of the baby, especially at night. She 
should be put in as good physical condition as possible; 
she should get out of doors. 

Giving both breasts at each feeding and temporarily 
shortening the nursing periods to 3 or even 2 hours, 
thereby increasing the number of feedings, are the best 
stimulants available. 

Her appetite should be stimulated, so that she will take 
an abundance of milk and other nutritious food. The 
very common forced feeding beyond the natural appe- 
tite, is of questionable value. The general rules as to the 
diet previously spoken of should be maintained. It 
should, however, be remembered that an excessive diet 
may be assimilated by the mother's body without increas- 
ing the flow of milk. The fluids given should be palat- 
able to the nursing mother, and, as previously recom- 
mended, milk, weak tea, cocoa, farina, oatmeal, and corn- 
meal gruels as well as milk soups are probably the best. 
The fat and the protein of the milk can more especially 



NUTRITIONAL DISTURBANCES. 7\ 

be influenced by the diet. The fats are increased by over- 
feeding with fats and carbohydrates, with little or no 
exercise. They are reduced by limiting these articles and 
substituting vegetables, and by increasing the amount of 
exercise. The protein is also increased by overfeeding 
and limited exercise. The carbohydrates are less in- 
fluenced by the diet, but are also affected by an excess 
of carbohydrate feeding. Alcohol in the form of malted 
drinks has a temporary influence in increasing the quan- 
tity of milk and the amount of fat. The effect on the 
protein is less constant. We never force a woman to 
partake of alcoholic liquors unless she desires them, be- 
cause of the moral as well as of the physical effect. 

Direct Expression is the best means of breast stimu- 
lation. 

Stimulating massage may be applied to the breast in 
such a manner as to stimulate the whole gland. This 
can best be accomplished by two movements : ( 1 ) by 
gently raising the whole breast from the chest wall and 
kneading it gently between the fingers, and (2) by hold- 
ing the breast against one hand and making circular 
movements around the periphery with the outspread 
finger tips of the other hand, and gradually working from 
its base towards the nipple. 

Baths at a temperature comfortably cool (80° to 90° 
F.) should be taken daily to promote her general health 
as well as cleanliness. These should be followed by a 
brisk rubbing with a coarse towel. 

Steaming the breasts by the application of hot towels 
covered with oiled silk two or three times daily is of 
decided benefit. 

Galactagogues of any material value for permanent 
use are unknown. Pituitrin has been recommended for 
temporary stimulation. We have not had much experi- 
ence in its use. General tonics will often improve the 
digestion and tend to overcome the anemia, and in this 



72 INFANT FEEDING. 

way improve the general health, and thereby lactation. 
Feeding dried placenta has been recommended. 

2. Overfeeding. 

This condition is a rare one in the breast-fed baby, 
and, when present, in all but the very young and pre- 
mature, nature often provides its own remedy, either by 
regurgitation on the part of the baby, or by its refusal to 
nurse longer than to meet its needs, which latter soon 
leads to a lessened milk secretion. In the first weeks and 
months it may be of considerable importance, and may 
cause grave symptoms on the part of the infant — that is, 
before the mother's breast and the infant have become 
adapted to one another. 

Etiology. Although overfeeding in the breast-fed 
infant is rare when compared with overfeeding on arti- 
ficial food, yet next to underfeeding it is the most com- 
mon form of nutritional disturbance in the breast-fed 
infant. It is also more commonly present in infants fed 
by a wet-nurse than in infants nursing the maternal 
breast. 

Usually the error lies in too frequent nursing. 

Rarely it may be due to excessive quantities of milk 
taken at proper intervals. 

Occasionally it is due to milk which is excessively rich 
in fat. 

Pathogenesis. The normal infant's stomach on 
breast feeding empties itself in about two hours. When 
all the food has left the stomach, and is undergoing intes- 
tinal digestion, free hydrochloric acid is forming in the 
stomach. Free hydrochloric acid is antiseptic, and it also 
stimulates secretion of pancreatic juice and secretion of 
bile, both of the latter products being essential to proper 
intestinal digestion. 

For normal digestion it is therefore necessary that the 
stomach remain empty for some time after all the food 
has left it. When by too frequent nursings no time is 



NUTRITIONAL DISTURBANCES. 73 

allowed for the above described physiological process, or 
when by excessive quantities of food at proper intervals 
too great demands are made upon the hydrochloric acid, 
and the time of gastric digestion lengthened, with cor- 
responding shortening of the period of comparative rest, 
or the gastric secretion diminished by excessive fat, then 
we may expect disturbance of the normal digestion due 
to overfeeding. 

Symptoms. The earliest symptoms are regurgita- 
tion, diarrhea, and lessened appetite. These three symp- 
toms are reactions of the organism to excessive intake of 
food attempting to get rid of the excess. 

Regurgitation occurs at first occasionally only, imme- 
diately after nursing, and without any discomfort on the 
part of the infant ("spitting"). The regurgitated fluid 
is often unchanged milk. This is usually the first pre- 
monitory symptom. 

Diarrhea follows when overfeeding continues and re- 
gurgitation becomes insufficient to rid the body of excess 
of food. The stools are more frequent than normal, and 
contain undigested particles of food. 

Lessened appetite, although present in many cases, 
may be replaced by symptoms suggestive of hunger, the 
infant taking the breast and nursing greedily. This ap- 
parent symptom of underfeeding and of hunger may 
wrongly be interpreted, and lead to additional overfeed- 
ing by giving the breast at even more frequent intervals 
to allay the apparent hunger and to quiet the restless 
infant. 

In many cases no other symptoms develop, the condi- 
tion undergoing a spontaneous cure. The breasts lessen 
their yield, and thus the cause of the condition disap- 
pears, or, on the other hand, the digestive power of the 
infant increases to such an extent as to be able to take 
care of the excess, if not too large. This accounts for the 
fact that frequently the above-named symptoms are 
neglected, since they usually produce improvement in 



74 INFANT FEEDING. 

the child's condition, and are regarded as passing dis- 
turbances without much importance. When, however, 
they are entirely neglected, and excess of the food is con- 
tinued, or even increased, due to wrong interpretation of 
symptoms, then more serious symptoms develop, and the 
condition reaches a stage where spontaneous cure rarely 
occurs. 

Vomiting becomes habitual, occurring from a few 
minutes to half an hour after nursing. It is accom- 
panied by visible discomfort and straining on the part of 
the infant. The vomitus consists of curdled milk, mucus, 
and gastric juice. Between vomiting there is often pain- 
ful belching. Stomach shows distention, and empties 
itself only after three to four hours. Free hydrochloric 
acid is almost or entirely absent, the acid products of fer- 
mentation being present. The micro-organisms are in- 
creased in number and variety, due to stagnation and ab- 
sence of antiseptic free hydrochloric acid. 

Initial diarrhea is sometimes followed by temporary 
constipation, diarrhea setting in again. The evacuation 
is painful, and, with much gurgling and discharge of 
gases, fluid masses are squirted from the anus. The 
stools are watery, with white and dark green fragments, 
and of disagreeable, sour, pungent odor. The irritating 
feces often causes eczema and intertrigo in the ano- 
genital region. 

Abdomen is distended, tense, and often there is visible 
peristalsis. Intestinal colic causes restlessness and cry- 
ing; the infant's face gives expression to its pain, and, as 
the fermentation increases, its agony is increased, due 
to intestinal paresis. 

The infant becomes restless; its sleep is much dis- 
turbed, and even during sleep its features give evidence 
of its distress. 

The weight early becomes stationary, and in severer 
cases associated with dyspepsia loss of weight becomes 
marked. 



NUTRITIONAL DISTURBANCES. 75 

Complications. Dyspepsia. Accompanied by the 
milder evidence of intestinal irritation, evidenced by in- 
creased peristalsis, with its resultant colic, more or less 
numerous bowel movements of eight or ten or even more 
daily, sour and irritating, greenish-yellow in color, and 
containing numerous curds and much mucus. The but- 
tocks soon become reddened and intertrigo results. 

Intoxication, while rare in the breast-fed infant, may 
result when the dyspepsia is neglected. The baby be- 
comes drowsy and stuporous, paying little attention to 
its surroundings, and not infrequently develops a severe 
anorexia, all associated with more profound intestinal 
symptoms. 

In dyspepsia the intestinal findings dominate the pic- 
ture, while in intoxication they share their prominence 
with the added nervous symptoms. 

Pyelitis is not an infrequent complication in neglected 
dyspepsia and intoxication, and while it undoubtedly is 
frequently due to an ascending infection, it may re- 
sult from extension through the 'blood stream or the 
lymphatics. 

Eczema not infrequently results from overfeeding in 
the breast-fed infant, and is usually seen in the fat type 
of infant who is otherwise healthy. 

Pylorospasm and gastric dilatation are not uncommon 
in the neglected cases. 

Acidosis may develop in the extreme cases, associated 
with great loss of weight, but this is rare. 

Diagnosis. In the presence of symptoms suggestive 
of overfeeding, positive diagnosis is made by determin- 
ing exactly the amount of milk taken by the infant, and 
comparing this amount with what an infant of the same 
weight and of the same age should get. The method of 
this determination has been described in detail under the 
treatment of underfeeding. 

If, however, the food is found to be quantitatively cor- 
rect, occasionally information of value may be obtained 



76 INFANT FEEDING. 

by examining the quality of the milk chemically, espe- 
cially as to its fat content. The specimen for examina- 
tion should be taken under precautions pointed out under 
Examination of Human Milk. By making proper etio- 
logical diagnosis, valuable indications for rational treat- 
ment are obtained. 

If a careful search is made for the etiological factors 
in the common illnesses of infants, which are so fre- 
quently charged to overfeeding, one will be surprised to 
find that the error lies in the diagnosis, and that in most 
cases the condition is not due to overfeeding. This leads 
us to warn against the only too frequent habit of wean- 
ing infants without a careful study of the exact cause 
of the infant's trouble. 

Treatment. Prophylaxis of this disturbance is of 
importance, and consists of giving the nursing mother 
proper instructions as to the nursing, especially as to its 
frequency, and seeing to it that the rules for nursing, as 
laid down elsewhere, are observed by the nursing mother 
In wet-nursing, more caution is necessary, especially in 
those wet-nurses who have an abundance of milk, which 
is frequently the case in a wet-nurse whose own child is 
much older than the infant to be nursed. 

A very important point to impress both on the mother 
and also on the wet-nurse is the fact that crying of the 
infant is not always due to hunger, and that offering the 
breast should not be used as a means for quieting the 
child. 

When the initial or mild symptoms only are present, 
then correction of the nursing habits is usually sufficient, 
the infant improving without any special treatment. 

When the error lies in too frequent nursings, it is best 
and often completely relieved by lengthening the feed- 
ing intervals to three or, even better, four hours. 

It is of equal importance that the infant should not be 
left too long at the breast. The best average nursing time 
being about fifteen minutes, with twenty minutes as the 



NUTRITIONAL DISTURBANCES. 77 

maximum. However, when the flow of milk is very free, 
it may be necessary to reduce the nursing period to even 
three to five minutes, it being a fact that most infants 
take about 75 per cent, of their entire meals in the first 
five minutes at the breast. It is always well at the begin- 
ning of such an experiment to weigh the baby after a 
two, three, five, ten, and twenty minutes period to ascer- 
tain the exact amount which the baby obtains from the 
particular breast which it is nursing, so that conclusions 
may be drawn definitely as to the time it is to be left on 
each breast. 

If placing the infant at the breast for short periods 
with long intervals does not give results, it is advisable 
to express the milk, and feed in small quantities from the 
bottle. And if another baby be at hand, it may be placed 
upon the breast to keep up the supply. Or when a wet- 
nurse is available for temporary use, the babies may be 
exchanged. 

Weaning should under all circumstances be considered 
only as the last resort, after all other methods of adapt- 
ing the infant to the breast have failed. 

An excessive amount of fat in the milk is more often 
due to an excessive intake of food in general on the 
mother's part than an excess in any one element, and can 
be diminished best by cutting down the food as a whole, 
lessening the amount of all food. 

When the condition has progressed farther, and the 
symptoms have become more serious, then it is necessary 
to treat the infant also. The treatment consists in empty- 
ing the stomach and the bowels of the overload of fer- 
menting food, and of rest for the digestive apparatus, 
both these objects being achieved by giving a bland diet, 
consisting of boiled water or weak tea sweetened with 
saccharin, for twelve hours, the digestive tract getting rid 
of its contents spontaneously. 

If the symptoms improve upon this treatment, the 
nursing should be gradually resumed by giving two 



78 INFANT FEEDING. 

breast feedings in the twenty-four hours following the 
period of starvation, substituting for the other nursings 
bland liquids, and increasing cautiously the number of 
nursings. 

If on withholding the food, vomiting does not cease, 
then it is necessary to wash out the -stomach. 

Irrigation of the bowel is often necessary, and aids in 
removal of fermenting intestinal contents, and allows 
also the gases to pass, thus relieving the distention and 
colic. Only when change of diet and irrigation are not 
sufficient, then the use of purgatives is advisable, castor 
oil being just as efficient and less harmful than the fre- 
quently preferred, calomel. 

Colic usually disappears on correction of the diet, and 
after the intestinal tract has been cleansed of its irritating 
contents, and of gas. Massage to the abdomen will aid 
the passage of gases which cause distention, when the 
bowels tend to become paretic. In severe pain, warm 
applications to the abdomen give relief. If these meas- 
ures fail to bring relief, and the pain is such that the in- 
fant is deprived of sleep, a mild sedative in small doses 
may be given. 

Feeding of powdered casein in amounts varying from 
6 to 8 Gm., dissolved in 30 to 60 mils of water, two or 
three times daily will relieve colic in many infants, in 
all probability due to lessening of intestinal peristalsis. 

There is a class of infants who, although they are gain- 
ing progressively in weight, cry a great deal, expel a 
great deal of gas, and perhaps have a green stool now and 
then. It is almost criminal to take such infants off the 
breast, although the temptation to do so is very great, 
because of the worry they cause the mother, and conse- 
quent harassing of the physician. Such an infant will 
frequently cry for six, eight, ten, or twelve hours out of 
the twenty-four, and still make a good gain in weight 
each week, in which case it is very probable that the 
infant is being overfed, and the food supply should be 



NUTRITIONAL DISTURBANCES. 79 

reduced. The mother's diet and general habits should 
receive attention. 

3. Congenital Debility, with Resulting Impair- 
ment of Vital Functions. 

Etiology. Premature birth is the most important 
condition causing debility associated with deficient func- 
tionating power of the digestive organs. Method of 
feeding premature infants will be detailed later in a 
special chapter. 

Hereditary weakness of the offspring caused by dis- 
ease in the parents is frequently the cause of deficient 
morphological and functional development of the diges- 
tive organs, and thus it is often the underlying cause of 
nutritional disturbances, which are more commonly 
chronic in character. Tuberculosis, syphilis, and alco- 
holism in parents stand at the head of the conditions 
causing hereditary weakness, even when the offspring 
does not inherit the disease itself. 

Malformations of the digestive tract (cleft palate, 
sublingual tumors, pyloric stenosis, atresias of the intes- 
tinal tract, Hirschprung's disease, etc.) from any cause 
compromise its functional capacity usually, but in most 
cases they cause serious conditions necessitating surgical 
interventions, and only rarely do they produce simple 
nutritional disturbances amenable to dietetic means, and 
therefore they belong to the domain of surgery. 

Symptoms. As may be expected, symptoms of these 
so diverse conditions vary. Hereditary weakness may 
often be suspected when symptoms of nutritional dis- 
turbances develop even when the infant is given the best 
care possible, and the milk is quantitatively and quali- 
tatively correct. Symptoms of underfeeding or of over- 
feeding, as described previously, may be present, de- 
pending upon the etiological factor. 

Diagnosis. Careful examination for malformations, 
and thorough family history, in cases of suspected 



80 INFANT FEEDING. 

hereditary weakness are of chief importance in making 
the etiological diagnosis. 

Treatment is usually determined by the pathology, 
and by the nature of the particular nutritional disturb- 
ance which developed. 

4. Intercurrent Parenteral and Enteral Infections. 

Etiology. Diseases both in the mother and in the 
infant are to be considered in etiology of this condition. 
In the mother the most important are the general infec- 
tious diseases, e.g., puerperal fever and sepsis, typhoid, 
pneumonia, etc., and local infections of the breast, and 
also of the upper respiratory passages. In the infant 
there are parenteral infections, that is, infections outside 
the digestive tract, e.g., pharyngitis, tonsillitis, pneu- 
monia, pyelitis, bronchitis, and enteral infections, or in- 
fections of the intestinal tract, which will be discussed 
under a special heading. 

Symptoms. In the conditions dependent on the 
mother's health the symptoms will vary first with the 
quality and quantity of her milk supply, which will have 
an effect on the child's general nutrition, and, secondly, 
may result in direct parenteral or enteral infections of 
the infant. 

In those dependent on infections of the infant itself we 
invariably find evidences of nutritional disturbances, 
whether the infection be local, systemic, or confined to 
the intestinal tract. The clinical picture varies directly 
with the degree of disturbance of the metabolic function. 
While, as a rule, the enteral infections are more com- 
monly associated with grave disturbances of the infant's 
nutrition, it is not uncommon to find the infant severely 
affected in its ability to meet its nutritional needs by 
the parenteral infections. While any one of the above 
enumerated etiological factors may give rise to a marked 
clinical picture, it is to be remembered that this class of 



NUTRITIONAL DISTURBANCES. 81 

disturbances in the breast-fed infants are of minor im- 
portance as compared with those of the artificially fed 
(see Nutritional Disturbances in Artificially Fed In- 
fants). 

Diagnosis. The diagnosis of the primary seat of in- 
fection in the infant is of considerable importance in de- 
ciding the method of treatment. 

Treatment. Parenteral infections rarely call for re- 
straint in administration of food because of the asso- 
ciated anorexia, and the infant should be nursed (if pos- 
sible without danger to the mother) directly at her 
breast. 

In the case of enteral infections it may be necessary to 
withdraw the maternal milk and replace it by a short 
period of starvation, to be followed by small quantities of 
breast milk, either taken directly from the breast during 
short nursings, or it may be best to feed small quantities 
of expressed milk to the infant at regular intervals. 

Not infrequently it becomes necessary to feed these 
infants by catheter in order to sustain them. And this 
method of introducing their food should be begun suffi- 
ciently early to avoid a catastrophe. 

Under no circumstances should they be placed upon 
food other than the mother's milk when her state of 
health and the quality of her milk permit. 

Inert fluids, such as water, weak tea, broths made from 
young meats and young fowls, and cereal decoctions 
should be given between feedings to insure a sufficient 
intake of water. A careful record should be kept of the 
twenty-four-hour quantity of all fluids administered, in 
order to insure the child a sufficient water and food ad- 
ministration. 

For conditions in the mother which would justify 
weaning, see chapter on Weaning and Contraindications 
to Nursing. 

c 



82 INFANT FEEDING. 

5. Idiosyncrasy Towards Mother's Milk. 

Etiology. This condition is very rare, although it 
may not be denied that it exists. The etiology and patho- 
genesis are as yet little understood. 

Diagnosis. The diagnosis of this disturbance should 
be made by exclusion of all other causes that may give 
rise to a similar symptom-complex. It may be confirmed 
by the change of the milk either by substituting a wet- 
nurse or cow's milk for maternal nursing, whereupon the 
symptoms improve. 

The cases in which the mother's milk is totally unfit 
for the infant are exceptionally rare. More recently 
considerably more attention has been given to the effect 
of the mother's diet on the quality and quantity of her 
milk secretion. The instruction so commonly given to 
the mother, to the effect that she may eat whatever she 
likes, has, in the light of more recent investigations, 
shown need for modification. The effect of the diet of 
the mother on the milk must be considered under two 
headings: First, what foods disagree with the individual 
mother to the extent of affecting the quantity of her milk 
supply. The mother will be the best judge as to what 
foods she, herself, finds it desirable to eliminate from 
her diet because of an undesirable effect upon herself. 
More important, however, from the standpoint of food 
idiosyncrasy, is the result following the eating of foods 
by the mother which she, herself, may relish, but which 
may have an undesirable effect on the child. It is well 
known that eggs, some cereals, fish and sea foods, certain 
meats, chocolate, and even cow's milk proteins may re- 
sult in a sensitization of the infant when ingested by the 
mother. The more recent work of O'Keefe 1 demon- 
strated the frequency of such a sensitization in eczema. 
He studied forty-one cases of- this condition in breast- 



1 O'Keefe: Eczema in Breast-Fed Babies, Boston Med. and 
Surg. Jour. August, 1921 ; 185, No. 6. 



NUTRITIONAL DISTURBANCES. 83 

fed infants, and 61 per cent, of his cases showed a posi- 
tive reaction to one of the cow's milk proteins. Forty- 
one per cent, showed a positive reaction to one of the 
egg proteins, two cases to oats, and one to wheat. About 
20 per cent, of the positive cases showed a response to 
both milk and egg proteins. Apparent cure in about 20 
per cent, followed the omission or limitation in the ma- 
ternal diet of one or more food proteins to which the 
infant was sensitive. 



CHAPTER VII. 

METHODS OF FEEDING PREMATURE 
INFANTS. 

1. Infants Nursing at the Breast. 

In most cases we do not feed the more developed pre- 
mature infant on the first day. It may be wise, however, 
to place the infant on the breast two or three times dur- 
ing the last half of the first day, after the circulatory and 
respiratory functions are well established, so that the in- 
fant may become accustomed to nursing. We are now 
confronted with two important factors, first, the ability 
of the infant to nurse the breast; and secondly, sufficient 
and proper development of the nipples to allow of the 
infant's properly grasping the same. If the infant is 
sufficiently developed to take hold of a well-formed 
nipple, it should be placed at the mother's breast regularly 
at three-hour intervals on the second day, for two- or 
three- minute periods, even though there is little hope 
of the breasts secreting at this time. By this means the 
infant is trained to expect its food at regular periods, 
and at the same time the maternal breast is stimulated. 
When a wet-nurse can be supplied in the home who has 
her own infant with her, the latter can be used to stimu- 
late the breasts of the mother, and the new infant can 
have one of the wet-nurse's breasts set aside for its use. 
Where the infant is very weak, the breast set aside for it 
can be made to secrete more freely by simultaneously 
placing the wet-nurse's baby on the opposite breast dur- 
ing the period of nursing. 

We have found this to be a very valuable expedient. 
However, with this latter method of procedure the quan- 
tity taken by the premature infant must be accurately 
measured to prevent overfeeding by weighing the in- 
(84) 



FEEDING PREMATURE INFANTS. 85 

fant before and after the nursing period. Nursing di- 
rectly from the breast has the added advantage of de- 
veloping the baby's sucking muscles, preventing con- 
tamination of the milk, and stimulating the breasts by 
the natural method. It should, however, be remembered 
that a weak infant may nurse the maternal breast for a 
considerable time, and yet the amount of food taken may 
be insufficient. This is especially true of that class of in- 
fants who are inclined to go to sleep at the breasts. Here, 
again, weighing is of the utmost importance. When the 
infant is too weak to nurse sufficiently to satisfy its 
needs, as ascertained by weighing, the nursing should be 
followed by substitute feeding with expressed milk, either 
by the bottle or one of the other methods to be described. 
These rules do not apply for the first and second day, 
when only rarely more than four or five meals should be 
given. In very weak infants, and those subject to re- 
gurgitation after taking small quantities of milk, it may 
be necessary to feed more frequently in periods varying 
from two to two and a-half hours, as may be indicated 
by the quantity retained, or better results may be obtained 
by catheter feeding (to be described later) with four- 
hour intervals. 

2. Infants Too Weak to Nurse the Breasts. 

In this class of infants, wherever possible, they should 
be fed without being removed from their bed or the in- 
cubator, if used, so as to avoid all careless exposure of 
the infant. The cause of inability to nurse may be due 
to several factors: (1) Infants unable to swallow; this 
is usually because of improper development of the center 
in the medulla, or lack of co-ordination on the part of 
the pharyngeal muscles and tongue. This is usually made 
evident by the milk flowing from the dependent part of 
the mouth. In such cases it is generally necessary to re- 
sort to catheter feeding. (2) Those too weak to nurse, 



86 INFANT FEEDING. 

and who may appear to be almost dead ; in this class there 
is great danger in handling the infant, and it is best fed 
in the bed. (3) Those who will not suck. (4) Those 
vomiting after every feeding. (5) Those becoming 
cyanotic after feeding. In the latter cases it may even be 
necessary to resort to such methods as gentle friction, 
artificial respiration, best performed by gently compress- 
ing the thorax, warm baths, oxygen, etc. 

Methods. One of the following methods can be se- 
lected for feeding these infants : 

1. The nasal spoon, which can be used either by pour- 
ing the milk slowly into the nose or into the mouth. The 
latter is to be preferred, because of the dangers due to 
decomposition of the milk in the nose and naso-pharynx, 
with secondary development of rhinitis and pharyngitis. 

2. A medicine dropper for mouth feeding. This is 
possibly one of the best methods for feeding this class 
of infants, as it is simple of application, and a small 
dropper is easily obtainable. As in all other methods, the 
food should be administered very slowly. 

3. Nursing From a Bottle. For this purpose the small 
nipples commonly sold on doll nursing-bottles are of the 
proper size, and can usually be obtained of proper quality. 
We have not infrequently perforated the rubber end of 
a medicine dropper and used it for this purpose. The 
bottle to be used can either be an ordinary 1 -ounce or 2- 
ounce medicine bottle, or, better, the special bottle which 
was designed by the author for this purpose. This bottle 
holds 2 ounces of milk, is graduated in cubic centimeters, 
has a ground glass neck which coapts perfectly with the 
bulb on the special breast-pump, and which after being 
filled is corked with a ground glass stopper, and which 
has the added advantage in that the milk is in no way 
handled after it leaves the breast. 

4. The Breck Feeder. This has the added advantage 
that the milk can be passed into the pharynx without 
effort on the part of the child when it is too weak to 



FEEDING PREMATURE INFANTS. 



87 



nurse. This has the one disadvantage of too rapid feed- 
ing if not properly controlled. 

5. A rather slow but satisfactory method of feeding 
the infants is by expressing the milk directly from the 
nipple into the infant's mouth during the feeding period. 



Fig. 5. — Breck feeder for premature infants. 

6. Catheter Feeding by Mouth (gavage). For this 
purpose a small funnel is attached either directly or by 
means of a short piece of rubber tubing with a glass 
connection to rubber catheter. A Nelaton catheter is 
used (best a No. 12 French), 1 about 25 to 40 cm. long 
(10 to 16 inches), marked in centimeters or inches, so 



1 No. 12 French — No. 8 American — No. 5 English. Diameter — 
4 mm. 



88 INFANT FEEDING. 

that at all times its position can be estimated. The in- 
fant should be fed in the incubator, its crib, or on the 
dressing table. Its head should be slightly lower than 
the body. The passage of the catheter is usually effected 
without difficulty by grasping it as one would a pen, and 
passing it in the midline to the pharynx, gradually push- 




Apparatus for garage and lavage. 



ing it into the esophagus. This is usually accomplished 
without difficulty, because of the poorly developed 
pharyngeal reflexes, and rarely results in retching or 
vomiting. In infants who retch during the passage of 
the catheter, vomiting may be expected because of the 
fact that these latter infants not infrequently belong to 
the spasmophilic group. The danger of passing the 
catheter into the larynx is minimal. It is rarely necessary 
to pass the catheter more than 10 centimeters (4 inches) 



FEEDING PREMATURE INFANTS. 



89 



beyond the infant's lips, and we have found it equally as 
practical to limit the passage of the catheter to 7.5 centi- 
meters (3 inches). In most instances this does not reach 
the stomach, but has the added advantage of preventing 




Fig. 7. — Feeding baby with catheter. 



trauma to the cardiac end of the stomach and the gas- 
tric mucosa. When a graduated catheter is not at hand, 
it may be marked at 10 centimeters with indelible ink, 
and this used as the maximum point for passage. A 
fairly safe maximum for the passage of the catheter can 
be ascertained by measuring the distance from the glab- 



90 INFANT FEEDING. 

ella to the epigastrium in the individual infant. The de- 
sired quantity of milk is allowed to flow into the stom- 
ach, slowly, by raising the funnel only very slightly above 
the level of the body. After feeding, the catheter is 
firmly compressed to avoid all leakage into the pharynx, 
and the catheter then removed, but not too rapidly. The 
milk to be fed should be measured in a graduated glass, 
and the latter kept close at hand in order that the amount 
given can at all times be estimated. 

A complete record of every feeding, both as to the 
time and the amount, should be kept. This is especially 
important in institutions where the nurses have a number 
of infants to observe, and is greatly facilitated by a time- 
clock registering the day, hour, and minute of each feed- 
ing. The nurse records the quantity of milk taken, which 
in breast-fed infants is obtained by weighing the infant 
both before and after feeding on an accurate scale, or in 
infants too weak to nurse by measuring the quantity in 
a graduated glass before feeding. 

3. Proper Time for Beginning Regular Feeding. 

Due to the tendency toward the rapid development of 
acute inanition in this class of infants, the greatest dan- 
ger is that of too long delay in establishing regular feed- 
ing. Therefore it is often impossible to wait for the 
mother's milk to appear. We believe that it is, however, 
unwise in most instances to attempt to feed with milk 
during the first twelve to twenty-four hours, rather pre- 
ferring to allow the circulatory and respiratory organs 
opportunity for proper accommodation to their new en- 
vironment. During this time the loss of body fluids 
through evaporation from the skin and respiratory tract 
due to the warmth of the incubator, and the excretions 
through the kidneys and bowels, should be recompensed 
by the regular administration of water or some other 
inert fluid. 



FEEDING PREMATURE INFANTS. 91 

We endeavor to administer by the tenth day about one- 
sixth of the body weight of water (inclusive of that 
contained in the milk if given) in twenty-four hours. 

In smaller infants the first milk is given diluted one 
or two times during the first four days. After the first 
twenty-four hours water can be administered partly with 
the food, and otherwise between feedings. If for any 
reason the water is not well retained when given by 
mouth, it can, at least in part, be administered by rectum. 
Example: An infant weighing about 1200 grams should 
receive 200 mils of water; should this infant receive 50 
mils of milk, this can be diluted with 50 mils or more of 
water or sugar solution, and the remaining 100 mils ad- 
ministered between feedings. 

If a stimulant is indicated, a few drops of brandy (6 
to 15 in twenty-four hours) may be added to the water 
or sugar solution during the first twenty-four hours. 
Half strength of Ringer's solution prepared as follows 
can be used to very good advantage for rectal adminis- 
tration : 

NaCl 7.5 Gm. 

KC1 0.1 " 

CaCl 0.2 " 

Water 1000.0 mils. 

We have made it a rule never to start milk feeding 
until after the first bowel movement. Not infrequently 
the removal of meconium may be accomplished by the 
administration of a small quantity of physiological salt 
solution through a catheter passed one or two inches 
into the rectum. This is done to remove the meconium 
before infection of the intestinal tract through the 
administration of food. Occasionally it is necessary 
to administer 5 drops of castor oil to obtain slight 
purgation. 



92 INFANT FFFD1NG. 

4. Feeding From the Second to the Tenth Day. 

It must be remembered that the general rules as ap- 
plied to the feeding of premature infants do not hold 
for the first ten days of life. The early feedings must 
necessarily be small, and the increases gradual. Two 
grave dangers present themselves during the first period 
of the infant's existence: (1) overfeeding and (2) star- 
vation, the latter usually resulting from an inability to 
supply sufficient quantity of human milk, following an 
attempt to await the natural secretion of the mother's 
breast. Overfeeding results either in vomiting or, more 
seriously, in stomach distention, which leads to asphyxia 
and cyanosis. Underfeeding in these weak infants soon 
leads to inanition. From the second day these infants 
should be fed regularly day and night, every two or, 
better, three hours, depending upon the infant's condition 
and the method of food administration. Not infre- 
quently where the quantities taken are very small, ten to 
twelve feedings are required in twenty-four hours. It 
may even be necessary in very weak infants to feed 
minimal quantities every hour. 

The question of the number of feedings will be dis- 
cussed in detail later. 

It is practically impossible to formulate definite rules 
for feeding premature infants during the first ten days, 
because of their great variation in weight and develop- 
ment. Therefore it becomes necessary to feed, each in- 
fant individually. 

During the first days it is often difficult in infants 
weighing 1000 to 1200 grams or less to feed more than 
20 to 50 mils of milk per day, and it may be necessary to 
limit the food to this quantity during the first ten days. 
It is our rule to start feedings in this class of cases with 
a maximum of 4 mils per feeding, not infrequently using 
one-fourth or one-half human milk at the start, and the 
balance water. 



FEEDING PREMATURE INFANTS. 93 

The feedings should be increased by 1 mil at a time, 
and with the first evidence of regurgitation the quantity 
should remain stationary. Even in favorable cases dur- 
ing this time 30 to 50 calories per kilogram is likely to 
be the maximum that can be fed with impunity. 

The small feedings which can be assimilated, and the 
low energy quotient during the first two or three weeks, 
must be considered physiological, and as we rarely see 
an increase in weight with feedings of less than 90 cal- 
ories per kilogram, we are confronted by a rapid loss in 
body weight during the first days of life. In favorable 
cases this is usually followed by a stationary weight, or 
moderate fluctuations after the first four to seven days. 
Occasionally an infant is seen in whom there is sufficient 
water retention to avoid most of the initial loss in weight. 
One should, therefore, remember that even with fre- 
quent feedings with human milk, either at the breast, by 
hand, or gavage, it is rarely possible to feed more than 
the minimum requirements without causing vomiting. 

5. Feeding After the First Ten Days. 

There has been considerable discussion as to the food 
requirements of premature and underweight infants 
during the past few years. Budin gives us the rule that 
premature infants of less than 2500 grams after their 
tenth day require one-fifth of their body weight (200 
Gra. per kilogram of body weight), or 140 calories, while 
the full-term infant of normal development requires one- 
seventh of its body weight (140 Gin. per kilogram body 
weight), or 100 calories per day. On the other hand, 
Birk believes that the more fully developed premature 
infant, and those nearing the normal, will thrive on one- 
sixth to one-seventh of their body weight. 

Our opinion, based on a series of experiments made 
on a number of premature infants, is that they require 
higher food values, or at least the maximum required by 



94 INFANT FEEDING. 

normal infants, for the following reasons: (1) the 
greater body surface as compared with the body weight; 
(2) in the normal infant the requirements decrease with 
the age, and therefore in the premature the quantity re- 
quired varies inversely with the fetal age after the first 
weeks of life; (3) the need for body development is 
relatively greater in the premature than in the full-term 
infant; (4) a kilogram of body weight in the fat-poor 
premature infant cannot be taken as parallel in feeding 
to the well developed full-term infant, with its prepon- 
derance of fatty tissue. This latter point must also be 
considered in the feeding of the marasmic infant, to 
obtain a proper gain in weight as compared with the 
lower requirements in the fat, full-term infant. 

6. Number of Feedings Daily. 

Our own experience has led us to adopt a conservative 
position in that we have grouped the infants nursed at 
the breast or fed from the bottle or by feeders into two 
general classes: (1) those weighing under 1500 Gm., 
and (2) those above this figure, based on the tendency 
of the smaller infants to become exhausted when the 
feedings are long continued. The former are fed at 2- 
hour intervals during the day, and 3-hour intervals at 
night, as follows: 6 a.m., 8 a.m., 10 a.m., 12 m., 2 p.m., 
4 p.m., 6 p.m., 9 p.m., 12 p.m., and 3 a.m. — 10 feedings 
during the twenty-four hours. The larger infants are 
fed on a 3-hour basis, 8 feedings being given during the 
twenty-four hours. These figures should in no way be 
construed as arbitrary. All feedings are more or less 
dependent upon the general development of the infant in 
relation to its digestion and metabolism, its retention, 
and upon the larger quantities of food necessarily given 
to meet its nutritional requirements, and a careful atten- 
tion to gastric distention, regurgitation, asphyxia, cya- 
nosis, and other respiratory complications. 



FEEDING PREMATURE INFANTS. 95 

It has been our personal experience to meet with con- 
siderable difficulty in attempting to meet the large food 
requirements in smaller infants without resorting to 
catheter feeding. In these we have adopted the longer 
interval between feedings, of four hours with six feed- 
ings in twenty-four hours, the individual meal in catheter 
feeding being greater in quantity. Notwithstanding the 
fact that catheter feeding offers little difficulty and few 
dangers in experienced hands, this may not be true with 
those not skilled in its use. A considerable number of 
our cases have, however, thrived satisfactorily on quan- 
tities of milk less than one-fifth of their body weight per 
day, and one should always remember that it is a safe 
axiom not to force the feeding in these cases as long as 
their general development is progressing satisfactorily 
and their weight curve is good. 

7. The Amount of Each Feeding. 

The statistics as to the stomach capacity for food in 
premature infants indicate that this varies within con- 
siderable limits, even in infants of the same fetal age, as 
does also their ability to digest and assimilate food. 
The weight and length, naturally excluding congenital 
diseases and deformities, will be far more dependable as 
a guide to stomach capacity than the fetal age. As no 
definite rules can be established governing the amounts 
of individual feedings, we begin with what could be 
considered minimum quantities and gradually increase 
the amount of feedings as the infant develops an ability 
to digest it. It is our rule, as previously stated, during 
the first few days to feed small total quantities varying 
from 20 to 50 mils of milk per day, dividing these totals 
by the number of feedings to be administered (eight to 
ten), thereby feeding from 2 to 6 mils of milk per feed- 
ing. The feedings can then be increased by 1 or more 
mils at a time, and in the absence of vomiting the in- 
dividual feedings can be increased more or less rapidly 



96 INFANT FEEDING. 

until the weight loss ceases or an increase in weight oc- 
curs. Even in favorable cases, weighing over 1500 Gm., 
75 to 150 mils per kilogram weight (50 to 100 calories per 
kilogram) is likely to be the maximum that can be fed 
with impunity or safety during the first ten days. 

8. Daily Gains. 

These are not necessarily in proportion to the changing 
quantity of milk administered, as many factors, such as 
condition of the bowels, quantity of the urine passed, 
temperature of the infant's surroundings, will neces- 
sarily influence the weight. This is more especially 
noticeable in observations continued during a short period 
of time. An average greater daily gain than 20 Gm. 
is unusual when the infant's food is limited to one-fifth 
of its body weight. An average of from 10 to 20 Gm. 
daily can in most cases be considered satisfactory. 

9. Artificial Feeding. 

There can be no comparison between the results to be 
expected in feeding premature infants on human milk, 
and those to be obtained with artificial food. Witb 
human milk taken from a well regulated department for 
wet-nurses the milk can be obtained fresh, practically 
sterile ; it is more digestible ; its constituents are of the 
quality and in the proportions required for the growth 
and development of the human body ; and it is live, and 
contains many of the immunity-conferring properties, as 
evidenced by the resistance of a breast-fed infant to in- 
fections and contagious diseases. Most of these proper- 
ties and advantages are lacking in the dead foods used 
in artificial feeding. Therefore, if it becomes necessary 
to resort to artificial feeding, the selection of the food, 
its preparation, and its adaptation to the infant must all 
be given the most painstaking consideration. Many 
varieties of artificial diet have been suggested by various 



FEEDING PREMATURE INFANTS. 97 

authors, such as simple milk dilutions, cream and top- 
milk mixtures, skim and buttermilk mixtures, malt soup 
preparations, condensed and evaporated milk, etc. The 
results with the various diets are to a great degree de- 
pendent upon the physician's intimate understanding of 
and directions for the use of the individual food. 

Quantity of Food. It must be remembered that the 
figures quoted for feeding on breast milk are the maxi- 
mum that can be assimilated, and in most instances these 
amounts more than fulfil the immediate needs of the 
infant's existence, and can be considered (and in most 
instances would be) excessive quantities for artificial 
feeding in the first few weeks of life, because of the 
greater difficulty in the digestion of cow's milk. One 
hundred calories per kilogram is the maximum quantity 
that can be digested by most premature infants, and in 
many instances one must be satisfied with a sustaining 
diet bordering on 70 to 80 calories, and they must at all 
times be closely watched for evidence of overfeeding, as 
it is dangerous to exceed the actual food requirements, 
and the first evidence of digestive disturbances or of in- 
tercurrent infections should lead to the feeding of human 
milk. During the first days the same rules for minimal 
feedings must be observed as in feeding with breast milk. 

Quality of Food. Opinions vary greatly as to the 
best food for an artificial diet. Ordinary milk, water 
and sugar mixtures are rarely well taken. Pf aundler sug- 
gests rich fat and low protein milk mixtures ; but in this 
feeding we have seen fat diarrhea resulting. Budin ob- 
tained the best results with peptonized boiled milk, using 
fresh pancreatic extracts for this purpose. Finkelstein, 
Oberwarth, Birk, Neumann, Von Reuss have obtained 
their best results through the use of boiled buttermilk- 
mixtures, prepared according to the following formulae: 

Buttermilk or skim milk 1000 

Flour (dextriflized ) 10 

Sugar (cane ) 40 

The above being used for the first feedings. 
7 



98 INFANT FEEDING. 

Buttermilk or skim milk 1000 

Flour (dextrinized ) 15 

Sugar (cane) 60 

For later feedings. 

Maltose-dextrin compounds can be substituted for the 
cane-sugar if desirable. 

Chymogen or pegnin milk has given us most satis- 
factory results in the artificial feeding of the premature 
infants. This latter preparation is little more than 
a boiled milk in which the curds are precipitated in 
a fine, flocculent form, about the size of that of human 
milk, before it is fed to the infant. It is best diluted be- 
fore use. This preparation should be started with 1 part 
chymogen milk and 3 parts water, following the direc- 
tions for increases in quantity and quality as given for 
human milk. Because of the low carbohydrate content 
of such mixtures, 0.5 per cent, of lactose should be 
added after the first few days, and the amount gradually 
increased to 3 per cent. 

When even only insufficient amounts of human milk 
can be obtained, artificial feeding should be used as a 
supplement and not as a substitute. 

10. Conclusions. 

1. The weight, temperature, stools, absence of ab- 
dominal distention, cyanosis and well-being of the infant 
should be the guide for increase in the infant's diet. 

2. The utmost care is necessary in increasing the diet 
of the infant during the first days of life. The gastro- 
intestinal tract offers the best evidence for increases. 
Vomiting and abdominal distention and associated cya- 
nosis are the prime indications for stationary or de- 
creased amounts of feeding. 

3. An initial weight loss during the first ten days must 
be considered physiological. 



FEEDING PREMATURE INFANTS. 99 

4. These infants, therefore, should be fed small quan- 
tities, frequently repeated, every two to three hours dur- 
ing the day -and night. 

5. After the first twelve hours human milk may be fed 
diluted with one or two parts of water and sugar, with 
a caloric value approximating 15 to 30 calories (20 to 40 
mils, % to 1% ounce of human milk to the kilogram of 
body weight). 

6. From the second day on, in the absence of indiges- 
tion, the food may be increased by 10 calories daily per 
kilogram (15 mils daily per kilogram). In the presence 
of digestive disorders greater care is necessary to main- 
tain the metabolic equilibrium (120 mils, 4 ounces of 
milk to the kilogram of body weight). 

7. It is of the greatest importance to administer a 
sufficient supply of water to counterbalance the rapid 
evaporation due to artificially heated and dried air, and 
the excessive excreta, more especially during the first 
few days. About one-sixth of the body weight of water, 
inclusive of that contained in the milk, should be fed in 
twenty-four hours by the tenth day. 

8. It is to be remembered that a standstill in the weight- 
curve, and indigestion with bad bowel movements, fre- 
quently result when 200 mils (140 calories) per kilogram 
are exceeded. 

9. All intestinal disturbances in premature infants 
should be given the utmost consideration. 

10. The method of administration of food in each case 
varies with the vitality of the infant. 

11. In all cases of prematurity, syphilis should be 
thought of ; and in cases in which there is the slightest 
suspicion, the infant must not be placed directly on the 
breast of a wet-nurse. 



PART III. 
Artificial Feeding. 



chapter I. 

RECENT PROGRESS IN ARTIFICIAL 
FEEDING. 

The presentation of the subject of artificial feeding 
without a review of the progress and evolution which 
our ideas on this subject have undergone during the past 
years might easily mislead the student to the belief that 
the last word in artificial feeding of infants has been 
said. The men who have given this subject the most con- 
sideration, we believe, would agree that much is to be 
hoped for in the future in artificial feeding. 

It is most difficult to present in a concise manner the 
best that we have learned in artificial feeding so that it 
may be practically applied, because of two very important 
factors which make for success: (1) a careful interpre- 
tation of the needs of the individual infant, and (2) ex- 
perience on the part of the feeder to meet those needs. 

It remained for the American school of pediatrics to 
do the pioneer work in placing artificial feeding on a 
scientific basis. 

Pepper and Meigs, of Philadelphia, gave us the first 
rational method in milk modification. They more espe- 
cially attempted to vary the percentages of casein in 
cow's milk, believing that the excessive quantity con- 
tained in cow's milk was in great part the cause of feed- 
ing difficulties. This was accomplished by diluting the 
milk and adding milk-sugar and cream to make up the 
deficiency in energy value. 
(100) 



PROGRESS IN ARTIFICIAL FEEDING. 101 

Rotch, of Boston, made further advances in infant 
feeding in that he taught us that fat and sugar, as well 
as protein, were important factors in the disturbances of 
the artificially fed infants. His work on percentage feed- 
ing, whereby he increased or decreased the various con- 
stituents of human milk to meet definite clinical pictures, 
was probably the first epoch-making advance in infant 
feeding, and his system of feeding has since been known 
as "the percentage method" of infant feeding. 

The German school, of which Rubner and Heubner 
were the chief advocates, gave us the so-called "caloric 
method" of feeding, by which they sought to provide the 
number of heat units required by the infant, basing their 
estimations on the infant's weight. Of this method we 
will have occasion to speak later. It is sufficient to state 
that we do not now use this as a method of feeding, but 
find a check on the caloric contents of the food of in- 
estimable value in determining the value of our mixtures 
in avoiding over- and under- feeding. The German 
school have never attempted the refinements in the per- 
centage composition of their mixtures as advocated by 
the American school. 

More recently Czerny and Finkelstein have taught us 
the dangers of overfeeding with whole milk, and also its 
individual ingredients, fat, sugar, and salts, individually 
and in combination. Their studies have, on the whole, 
ignored the proteins, in all probability due to the fact 
that protein disturbances other than those seen in infants 
suffering from an idiosyncrasy to cow's milk are for the 
most part limited to infants fed on raw cow's milk, 
while most of the Continental clinics have for several 
years fed boiled milk. Their studies and conclusions will 
be more fully discussed under the disturbances of arti- 
ficially fed infants. 

During the past few years there has been an increased 
tendency to boil cow's milk before feeding to the infants 
in American clinics, based on the desire to render the 



102 INFANT FEEDING. 

curd more fragile, and at the same time to destroy the 
pathogenic bacterial content of the milk. While this has 
many advantages, it must not be forgotten that it must 
necessarily cause changes, more especially in the fer- 
ments, vitamines, and salts, which are of vital importance 
to human economy. The ferments are believed to be im- 
portant fo the infant, and this importance has been em- 
phasized especially since the introduction of pasteuriza- 
tion and boiling of milk, for the reason that a high degree 
of heat destroys them. Some of the ferments are normal 
constituents of milk, such as lipase, galactase, lacto- 
kinase, and diastase. The absence of ferments in the 
milk indicates that it has been heated. Hamburger's 
studies on the biologic differences in human and cow's 
milk are unquestionably of vast importance, and though 
there has been a tendency in recent years to neglect this 
factor in infant feeding, we believe that it will again 
receive more important recognition in the near future. 
The changes caused in milk by boiling make it necessary 
to administer fruit and vegetable juices, non-dextrinized 
cereals, and other foods, such as codliver oil, to prevent 
the retarded development on the part of the infant. 



CHAPTER II. 
COW'S MILK. 

No method of artificial feeding can perfectly replace 
nursing or human milk feeding. This must be admitted, 
notwithstanding the many advances that have been made 
in infant feeding during recent years. 

When breast feeding is impracticable feeding with 
properly modified milk of other animals is necessary. 
Although cow's milk shows marked chemical, physical 
and biological differences from human milk, for practical 
reasons it has been found to be the one best suited for 
this purpose. 

How Cow's Milk Differs from Maternal Milk. The 
differences between these two milks summarized in a 
table which follows are greater than the table indicates. 
While cow's milk may be modified to approximate 
woman's milk in composition, it can never be just the 
same or just as good for infants. 

Cow's milk is more opaque than human milk, although 
the latter may contain a greater percentage of fat. This 
is due to the opacity of the calcium-casein, which is pres- 
ent in greater proportion in cow's milk. Cow's milk is 
faintly acid or amphoteric when freshly drawn, but ordi- 
narily is distinctly acid in reaction when consumed. 
Human milk is amphoteric or alkaline. 

There is three times as much protein in cow's milk as 
in human milk. The reason for this is obvious, when we 
recall that the ratio of the growth of the calf to that of 
the infant is about as 2: 1. Furthermore, the protein in 
cow's milk consists chiefly of casein (3.02 per cent.) and 
little lactalbumin (0.53 per cent.), while human milk con- 
tains 0.59 per cent, of casein and 1.23 per cent, lactal- 
bumin. The sugar in the two milks varies greatly in 

(103) 



104 INFANT FEEDING. 

amount, but not in kind. Cow's milk contains almost 
four times the amount of inorganic salts compared to 
woman's milk. In cow's milk calcium and magnesium 
are in greater proportion, while in woman's milk potas- 
sium and sodium bases are in relatively greater amounts. 
These differences have an important bearing upon 
infant's metabolism. There is no great difference in the 
average amount of fat in the two milks; however, both 
in human milk and in cow's milk the fat is the most 
variable constituent. 

The curd from cow's milk is usually tougher and in 
larger masses than in human milk. There are also dif- 
ferences in antibodies, ferments, etc. 

Cow's Milk Human Milk 

Amphoteric or acid Reaction Amphoteric or alk- 
aline 

1.029 to 1.034 Sp.gr 1.010 to 1.040 

3.5 per cent Proteins 1.5 to 2.0 per cent. 

3.02 per cent Caseinogen 0.5 to 0.75 per cent. 

0.53 per cent Lactalbumin 1.23 per cent. 

Clots in large lumpy 

curds Effect of rennin Clots in fine curds 

4.0 per cent Fat 3.5 to 4.0 per cent. 

4.5 per cent Lactose 6.0 to 7.0 per cent. 

0.75 per cent Salts 0.2 per cent. 

13 to 14 per cent. ...Total solids 12 to 13 per cent. 

86 to 87 per cent. . . . Water 86 to 88 per cent. 

Never sterile Bacterial contents . ..Practically sterile 

Biedert, whose theory found many followers at one 
time, believed that casein of the cow's milk was the dis- 
turbing factor in artificial feeding. 

The large, tough curds forming from the casein of raw 
cow's milk differ considerably from the fine flocculent 
curds of the human milk casein. Steps have been taken 
to make the cow's milk curd resemble the human milk 
curd in its physical properties, such as boiling the milk, 
titration, and addition of cereal waters, and it was found 
that this modification considerably improved the results 
of artificial feeding. 



COW'S MILK. 105 

The differences in the fat contents of the two milks 
have less frequently been drawn upon for explanation of 
frequent nutritional disturbances on artificial feeding, 
although it has positively been established that fat plays 
an important part in the nutritional disturbances of the 
artificially fed infant. The butter prepared from cow's 
milk contains 10 per cent, of volatile acids, while that 
prepared from the human milk only 1.5 per cent. And 
especially the irritant butyric acid glycerid, which is con- 
tained in 6 per cent, in butter prepared from cow's milk, 
is contained only in traces in human milk. The fat drops 
of cow's milk are also on the whole much larger than 
those of human milk. 

Lactose is the principal sugar in both cow's and human 
milk, average human milk containing 6 to 7 per cent., 
and cow's milk 4 to 5 per cent. This increased sugar 
contents of the human milk, with its' fermentation, ac- 
counts for the laxative effect of breast milk feeding when 
the milk is abundant. 

L. F. Meyer has experimentally shown that salts of the 
cow's milk, which vary both quantitatively and qualita- 
tively from those of human milk, have unfavorable in- 
fluence on children with nutritional disturbances. While 
we cannot from these experiments conclude that the same 
holds true for normal, healthy children, yet we have to 
admit that the salt contents of the two milks are of great 
importance in artificial feeding. 

Escherich and Hamburger were of the opinion that 
human milk contained ferments which favorably influ- 
enced the processes of metabolism. Salge found that 
tetanus and diphtheria antitoxins could be utilized by the 
infant only when fed in human milk, while when con- 
tained in the milk of other species they did not get into 
the body fluids of the infant. But whether these biologic 
differences are of great .importance to the infant remains 
to be proven. 



106 INFANT FEEDING. 

Although it seems probable, yet it has not been demon- 
strated that cow's milk feeding taxes the digestive func- 
tions of the infant's organism more than human milk 
feeding. 

Of great importance is the bacterial contents of the 
milk, the human milk being either sterile or of low bac- 
terial contents, while cow's milk is never sterile, and not 
infrequently its bacterial content is very high. Steril- 
ized, pasteurized, and certified milk were the practical re- 
sults of the efforts to obtain germ-free milk for infant 
feeding. 

The milk for infant feeding must come from healthy 
cows, must be obtained in clean manner into clean re- 
ceptacles, must be cooled very soon after milking in order 
to keep down the bacterial content, and kept cool after- 
wards. It must be delivered to the consumer as soon 
as possible in such a way as to prevent any contamina- 
tion, and must be handled in the home, cleanly, in sterile 
receptacles, and at all times be kept cool. 

The cow from which the milk is obtained must be 
entirely healthy, and be especially free from tuberculosis 
and glanders, tuberculin and mallein test being advisable 
as a routine, besides general examination of the cow. 
The cows must be kept clean, in a clean stable, which 
is well ventilated and drained. No dust, manure, or fod- 
der, except that used for immediate feeding, should be 
kept in the stable. The cows should be kept clean, but 
even then they should be cleaned again immediately be- 
fore milking. 

The milking must be done in a clean way and milk 
kept clean afterwards, in order that the bacterial count 
may be as low as possible. Dry feeding of the cows is 
preferable, since on this feeding the feces is less liquid, 
and cows can be kept clean with less difficulty. The 
milkers should be free from any communicable disease, 
and be of clean habits. The udders of the cows and the 
hands of the milker should be scrubbed with warm 



COW'S MILK. 107 

water and soap immediately before milking, and anti- 
septic solution may be applied afterwards. Milking 
should be done into covered cans, and milk made to pass 
through a filter first. The cans should be always cleaned 
immediately after the milk is poured out, first with cold 
and then with hot water, and also rinsed out with hot 
water before milking. The first few ounces of milk 
should be discarded, since this milk contains large 
amounts of bacteria that are washed out from the ex- 
cretory ducts. 

Cooling the milk after it is obtained is a very impor- 
tant step in the production of clean milk. The milk hav- 
ing been obtained with the above-described precautions, 
with as few bacteria as possible, should be cooled at 
once in order to prevent growth and multiplication of 
the bacteria that have entered the milk in spite of all the 
precautions. This is accomplished by special cooling ap- 
paratuses, or simply by pouring the milk into sterilized 
bottles, closing with sterilized cap, and putting on ice. 
The milk in bottles should be kept iced until it reaches 
the consumer, which should not take longer than twenty- 
four hours. 

In the home precautions should be taken to prevent 
additional contamination, and to keep the milk iced to 
prevent further growth of bacteria, until everything 
necessary is ready for making the proper mixture for in- 
fant feeding. Many good milks are spoiled on the door- 
step of the home between the hour of delivery and plac- 
ing the milk in the ice-box. All the utensils and vessels 
used for preparing the mixture must be perfectly clean 
and sterilized by boiling. As soon as the mixture is made 
it should be put into the ice-box again and kept there, 
portions being taken during the day for individual feed- 
ings, and warmed separately just before feeding. 

Certified Milk. The term "certified milk" was coined 
by Dr. Henry L. Coit, of Newark, N. J., who in 1892, 
needing good milk for his own baby, formulated a plan 



108 INFANT FEEDING. 

for the production of clean, fresh, pure milk under the 
auspices of a medical milk commission. The term "cer- 
tified milk," then, is the milk of the highest quality, of 
uniform composition, obtained by cleanly methods from 
healthy cows, under the special supervision of a medical 
milk commission. 

The use of the term "certified milk" should be limited 
to milk produced in accordance with the requirements of 
the American Association of Medical Milk Commission- 
ers. The first requisite in the production of certified 
milk is to enlist the co-operation of. a trustworthy dairy- 
man who enters into a contract with the medical milk 
commission. In accordance with the terms of this con- 
tract, the dairyman binds himself to comply with the 
specifications set forth, in return his milk is certified. 

The dairies are subjected to periodic inspections, and 
the milk to frequent analyses. The cows producing cer- 
tified milk must be free from tuberculosis, as shown by 
the tuberculin test and physical examination by a quali- 
fied veterinarian, and from all other communicable dis- 
ease, and from all diseases and conditions whatsoever 
likely to deteriorate the milk. They must be housed in 
clean, properly ventilated stables of sanitary construc- 
tion, and must be kept clean and properly fed and cared 
for. All persons who come in contact with the milk must 
exercise scrupulous cleanliness, and must not harbor the 
germs of typhoid, tuberculosis, diphtheria, or other in- 
fections liable to be conveyed by the milk. Milk must be 
drawn under all precautions necessary to avoid contam- 
ination, and must be immediately cooled, placed in steril- 
ized bottles, and kept at a temperature not exceeding 50° 
F., until delivered to the consumer. Pure water, as de- 
termined by chemical and bacteriological examination, is 
to be provided for use throughout the dairy farm and the 
dairy. Certified milk should not contain more than 10,- 
000 bacteria per cubic centimeter, and should not be more 
than thirty-six hours old when delivered. 



COW'S MILK. 109 

Inspected Milk. This term should be limited to 
clean, fresh milk from healthy cows, as determined by 
the tuberculin test and physical examination by a quali- 
fied veterinarian. The cows are to be fed, watered, 
housed, and milked under good conditions, but not neces- 
sarily equal to those prescribed in the production of cer- 
tified milk. Scrupulous cleanliness must be exercised and 
particular care be taken that persons having communi- 
cable diseases do not come into contact with the milk. 
This milk must be delivered in sterilized containers, and 
kept at a temperature not exceeding 50° F. until it 
reaches the consumer. There should be not more than 
100,000 bacteria per cubic centimeter of inspected milk. 
This milk should be pasteurized. 

Market Milk. All milk that is not certified or in- 
spected in accordance with the above definitions, and all 
milk that is of unknown origin, is classed as "market 
milk," and should be pasteurized. 

Frozen Milk. In our own experience we have found 
that many infants were made ill by feeding of raw frozen 
milk which has been rapidly thawed, and allowed to 
stand in a warm room. Not infrequently vomiting and 
diarrhea result. These symptoms are obviated when the 
milk is boiled. Pennington and her collaborators found 
very definite changes in milk after freezing. They found 
that when the milk is held at a temperature of 0° C. there 
is proteolysis of the casein, which is primarily of bacterial 
origin, and proteolysis of the lactalbumin, due primarily 
to the native enzymes of the milk. The action of these 
two agents together is more rapid than that of either 
alone. The bacteria and enzymes may break down the 
true protein and carry the breaking down through to pep- 
tones, even to amino-acids. There is a fermentation of 
lactose with the formation of lactic acid, which is largely, 
if not exclusively, due to bacterial action. The fat, so far 
as can be determined, is not affected except by the action 
of bacteria. 



110 INFANT FEEDING. 

Mixed Milk Versus Milk of One Cow. It is far bet- 
ter, other things being equal, to use the mixed milk of a 
herd in preparing a baby's food than the milk of one 
cow, because if the milk comes from one cow, and the 
cow is ill in any way, the baby is almost certain to be dis- 
turbed, whereas if one or two cows in a herd are ill, the 
milk from these cows will be so diluted that the baby will 
probably not notice it. On the other hand, it is, or should 
be, self-evident that the milk of a healthy cow properly 
fed and properly cared for, taken in the proper way, and 
kept under proper conditions, is better than the mixed 
milk of a herd which is improperly fed, and whose milk 
is not carefully obtained or carefully taken care of. 

Boiling, Sterilization, and Pasteurization. Before 
entering into a discussion of this subject, it is only fair 
to state that the general teaching in America of feeding 
with raw milk has led to the production of safe, clean 
certified milk in the large communities where so many 
fatalities were experienced through the feeding of un- 
clean milk. Any methods of handling milk which will in 
the least interfere with the proper production of clean 
milk, and lead to the feeling that unclean milk can be 
made safe for infant feeding by the application of heat or 
other methods, would be a backward step in infant feed- 
ing, and would necessarily cause dire results. While the 
European countries, as Germany and France, have ad- 
vocated feeding boiled milk for many years without fear 
of bad nutritional disturbances due to the changes in the 
milk, in America feeding with raw milk has until re- 
cently been favored. Increased experience with boiled 
milk, especially by those who have long used raw milk, 
leads to the growing conviction that boiled milk is more 
easily digested than raw milk by dyspeptic infants, and 
hence by the well infants. 

While we do not believe that feeding with boiled milk 
should be advised as a general measure, when it is pos- 
sible to obtain a good certified milk, and when the latter 



COW'S MILK. HI 

is to be placed in the hands of mothers and nurses who 
can be depended upon to keep the milk clean and whole- 
some through proper icing and handling, we do believe 
that when these requirements cannot be met, that it is 
safer even in well babies to feed a thoroughly sterilized 
milk, and that this can be done without danger of de- 
velopment of scurvy and rickets, when these feedings are 
accompanied by the administration of fruit juices, vege- 
table soups, and purees and codliver oil. 

Brennemann suggests that we must answer the follow- 
ing questions before deciding as to whether we should 
feed raw, pasteurized, or boiled milk: 

(1) Does raw milk offer advantages over boiled 

milk? 

(2) Does boiled milk offer advantages over raw 

milk? 

(3) Does pasteurization solve the problem? 

(4) Does certified milk solve the problem? 

In answer to the first question we must decide whether 
the changes caused in milk by boiling, such as partial 
coagulation of lacto-albumin, caramelization of some of 
the milk-sugar, its action on casein, inhibiting coagula- 
tion with rennin, etc., lessen the nutritive value of cow's 
milk as an infant food. We believe that the sentiment of 
American, German, and French clinics, in which boiled 
milk has been used for a long period of time, is on the 
whole, most favorable to boiled milk, with its lesser 
dangers. 

Constipation has been suggested as an argument 
against boiling milk. We believe that constipation in the 
bottle-fed baby is one of the safest earmarks of the well- 
being of the infant, and that only that constipation which 
is due to excessive feeding of fat, with too little car- 
bohydrate, and which will be later described, is an ex- 
ception to this statement. While with raw milk digestive 
disturbances are frequently seen before sufficient milk is 
given to properly nourish the infant, this is far less com- 



112 INFANT FEEDING. 

mon with boiled milk; in fact, it has not infrequently 
been our experience that we have overfed with boiled 
milk, because the infant handles it to so much better 
advantage. In digestive disturbances, with loose stools, 
it is digested to much better advantage than raw milk, 
which frequently results in formation of hard casein 
curds as well as fat curds. The assertion that feeding 
with boiled milk results in anemia, underdevelopment and 
rickets, we believe, is not well founded, and these condi- 
tions, when present, are due to other causes. Scurvy de- 
veloping during the course of feeding with boiled milk 
has never been seen in our experience, except when some 
of the proprietary infant foods have been fed in con- 
junction with boiled milk. That under certain conditions 
scurvy should develop in presence of long-continued feed- 
ing with boiled milk alone, is not to be denied. The dan- 
gers, however, are very remote, as testified to by the 
German and French clinicians. When such dangers are 
feared, they can easily be overcome, as previously sug- 
gested, by the feeding of fresh fruit juices and vegetable 
preparations together with the milk diet. 

Does boiled milk offer advantages over raw milk? 
Boiled milk when properly handled is relatively free 
from pathogenic micro-organisms, and if the milk, which 
has been boiled, was clean milk, also from their toxic 
products. 

Boiling in the home has the great advantage over com- 
mercial pasteurization in that, if the milk is raw and 
spoiled before it reaches the home, this can readily be 
detected by the housewife. While we know that certain 
pathogenic organisms may develop in the milk without 
giving evidence of their presence, and cause formation 
of toxic bodies which are not removed by boiling in the 
home, the latter process still offers every advantage over 
commercial pasteurization. Boiling milk in the home will 
most certainly remove the dangers from infection with 
tuberculosis, scarlet fever, streptococcus sore throat, ty- 



COW'S MILK. 113 

phoid fever, dysentery, and many other milk-borne dis- 
eases. The advantages of boiled milk in the presence of 
indigestion and diarrhea have already been mentioned. 
The small, flocculent curd of the boiled milk is also rapidly 
and more easily digested than the large, tough casein 
curds of the raw milk. The hard bean-like protein curds 
are never seen in stools of the infant fed on milk 
which has been thoroughly boiled, although we have oc- 
casionally seen them in overfeeding with cow's milk which 
has been heated by the double boiler process. These latter 
cases, however, are exceptions. 

Larger amounts and more concentrated mixtures of 
boiled milk can be fed than in feeding with raw milk. 
This is a distinct advantage in the beginning of the feed- 
ing of atrophic infants. This latter advantage is not to 
be overlooked. While the large percentage of healthy 
babies will apparently digest equally well raw and boiled 
milk within therapeutic limits, it will be found that most 
authors who do not resort to heating milk will, at least in 
some other way, modify the curd of raw cow's milk, 
either by simple dilution, by the use of cereal waters or 
an alkaline, such as lime water or sodium citrate. We 
agree with Brennemann in his statements that boiling 
commends itself as an excellent casein modifier, and that 
it effectually disposes of the majority of bacteriological 
problems when the milk is properly handled after boiling. 

Pasteurization versus Boiling. Pasteurization was 
first recommended because of the belief that boiled milk 
has scorbutic properties, which could not be laid at the 
door of pasteurized milk. The question of the relation- 
ship between boiled milk and scurvy has already been 
touched upon. Pasteurization in the home is not a very 
satisfactory process. Commercial pasteurization, even 
though properly carried out, is too distant from the 
probable time of consumption of the food to be a safe 
measure, unless the milk is properly handled after pas- 
teurization. The best argument presented by the advo- 



114 INFANT FEEDING. 

cates of pasteurization is that the milk is essentially a 
raw milk in so far as its physiological properties are 
concerned. 

Certified Milk versus Boiling. Clean certified milk, 
properly handled, both before and after it reaches the 
home, and where the cost is not prohibitive, when well 
digested by the individual infant, still remains the ideal 
food for artificial feeding. When these requirements 
cannot be met, boiling in the home is the best method 
for preparation of milk for the infant. 

Various Methods of Boiling Milk. In our own work 
we have resorted in most cases to the heating of the 
milk in a double boiler. This has several advantages in 
that the milk is heated in a closed vessel, and has then a 
less pronounced flavor than when heated in open ves- 
sels, and causes but little pellicle formation, unless we 
have a very thin column of milk. To overcome this lat- 
ter, we therefore recommend the smallest double boiler 
which can be obtained, and which will at the same time 
hold all of the milk which is to be prepared. The milk 
mixture is put in the inner receptacle, cold, and the water 
in the outer vessel also cold. The double boiler is then 
placed on the stove, and allowed to remain until the 
water in the outer vessel boils for six to eight minutes. 
While the milk heated in this manner forms a very much 
finer and softer curd than that of raw milk, it is not as 
fine as that of milk boiled directly over the flame. How- 
ever, in most cases, it answers all purposes, and has 
the advantages above enumerated. In the presence of 
gastric and intestinal indigestion and allied conditions, 
the finer curd of the milk boiled directly over the flame 
may be more suitable; and in exceptional cases, when 
boiling over the direct flame for three to five minutes does 
not give the desired result, milk boiled for 30 to 45 
minutes over the direct flame will offer further advan- 
tages, and this method is worthy of trial for temporary 



CHAPTER III. 

ADAPTATION OF MILK FOR INFANT 
FEEDING. 

From the foregoing it may be seen that there is no per- 
fect substitute for human milk in the feeding of the in- 
fant, and therefore every effort should be made to assist 
the mother in the nursing of her infant. 

Since all the attempts made to feed an infant on the 
food not primarily intended for this purpose are at- 
tempts at milk adaptation, we necessarily know that no 
single method can possibly meet the needs of all infants. 

And therefore it must be our object, first, to formulate 
our rules so as to make them safe and adaptable to the 
feeding of the majority of well babies, leaving the dis- 
cussion of exceptional and sick babies for further study. 
It must necessarily go without saying that the food 
recommended will be excessive for some and inadequate 
for others. Every organism has its individuality and its 
fixation coefficient, and every infant makes a different use 
of the food administered to it. All infants cannot, there- 
fore, be treated according to the same rule. 

While many excellent results have been reported with 
the various methods described for artificial feeding of in- 
fants, and some attempt has been made to place feeding 
on a scientific basis, we believe that we must concede 
that the methods are all more or less empirical, and the 
result will be in considerable degree dependent upon the 
wide range of food tolerance of the healthy infant. The 
successful physician must depend on the clinical ob- 
servation of the individual infant for the success of the 
method of feeding which he is using. Every formula 
with which we start feeding should be looked upon in 
the light of an experiment, and the reaction of the infant 
to this feeding should be carefully studied. 

(115) 



116 INFANT FEEDING. 

If these principles are borne in mind, many an ob- 
stacle to successful infant feeding will be avoided. 

We believe that the attempts toward ultra refinement 
of the infant's diet has led to considerable confusion, be- 
cause of the different conclusions of the various schools 
undertaking the work. Eventually, however, infant feed- 
ing will be placed on a thoroughly scientific basis. This, 
however, does not answer the pressing needs of to-day, 
which call for a safe and practical solution of the feed- 
ing problem for the everyday baby in everyday life. The 
parents commonly receive feeding advice from baby-food 
manufacturers; and. if feeding on one preparation is not 
successful, there is a rapid transition from one proprietary 
baby food to another, with untold detriment to the infant. 
In advancing the rules for feeding the normal healthy in- 
fant, with further suggestions for the underfed, on simple 
milk mixtures -with carbohydrates added, we desire to 
state that in our clinical experience we have found them 
safe for the baby and practical for the physician, which 
latter is neither to be overlooked nor taken lightly. 

We claim nothing original for these feeding sugges- 
tions, as they represent the more common practice of the 
Continent, and America as well. We have, however, 
formulated the rules which govern the application of 
simple milk mixtures, with carbohydrates added, in such 
a way that their application becomes more practical. 
Knowing that the advice herein given is founded on 
clinical experience, and that similarly good clinical re- 
sults have been obtained by others by various methods, 
we believe it advisable to briefly review the more popular 
methods of infant feeding as practiced today. 

Undiluted Whole Milk. While undiluted milk has 
been used with varying degrees of success by some 
German and French pediatricians (of the latter Budin 
being the foremost advocate), it may be generally stated 
that, on the whole, it is not well borne before the fourth 
month of life. If whole boiled milk is used in the feed- 



MILK FOR INFANT FEEDING. 117 

ing of the very young infant, the size of the individual 
meal must be greatly restricted over that as recommended 
for diluted mixtures, so that it will not exceed the caloric 
requirements of the individual. Budin recommended 
that all whole milk fed to an infant should first be boiled, 
which causes the protein to be precipitated in the infant's 
stomach in the form of a fine curd. This can be fur- 
ther facilitated by the addition of pegnin or chymogen, 
which causes the formation of the fine curds before it is 
fed to the infant, with no recoagulation in the stomach. 1 
Alkalinizing milk by the addition of sodium bicarbonate 
also results in the formation of fine curds. In some 
forms of vomiting, small quantities of a concentrated 
food will frequently be found of considerable value. As 
a routine measure of feeding, whole milk cannot be 
recommended. 

The Percentage Method or System of Feeding. This 
is frequently spoken of as the American method, or 
Rotch's method, because of the fact that Rotch, of Bos- 
ton, did much to popularize and systematize this method 
of feeding. Not only did he work out a system of 
formulae adapted to infants of varying ages and develop- 
ment, but he also was the means of establishing the first 
so-called public milk laboratory. The chief objections 
to this method, as originally described by Rotch, were 
its lack of flexibility and the difficulty of remembering the 
various formulae and their preparation. The followers of 
the Rotch school state that the percentage feeding, so- 
called, is not a method of feeding, but merely a method 
of calculation, and a means of obtaining relative accuracy 
in the preparation of infants' foods. They have sim- 
plified the method as originally applied, lengthened the 
feeding intervals, still retaining some of the original ideas. 
It has to a large extent been replaced by the simpler 
methods of milk modification. 



1 Brcnncmann, Archives of Pediatrics, 1917, 34, 81. 



118 INFANT FEEDING. 

Top Milk Feeding. In this method a definite number 
of ounces of the upper part of the milk, which has stood 
for a number of hours, is used as the basis for preparing 
the mixture to be fed. 

To successfully carry out top milk feeding, the per- 
centages of fat at various levels in 32 ounces (quart) of 
milk containing 4 per cent, of fat, and which has stood 
for six hours or longer, must be known : 

Upper 16 oz. has 7 per cent. fat. 

.< 20 <, „ 6 « „ « 

" 24 " " 5 " " " 

(1) This method endeavors to provide ample caloric 
values. In this respect the method may be regarded as 
successful. (2) There is the idea that casein is not 
very digestible, and that it is advantageous to feed casein 
in small quantities, making up the shortage in energy 
value of the mixture with fat. In the light of our pres- 
ent knowledge, however, we know that the casein of 
boiled or alkalinized milk, or when mechanically divided 
by the addition of cereals, is easily digested. (3) The 
attempt to produce a formula with the percentage of fat 
in the same proportion as is found in human milk, as 
well as larger amounts, which, however, frequently leads 
to fat indigestion, because of the greater difficulty experi- 
enced by many infants in handling large quantities of 
cow's milk fat. (4) The importance of the sugar and 
salt content of the mixture is underestimated. 

This method of feeding, nevertheless, has many ad- 
vocates, and we would advise that the above shortcom- 
ings of the method as originally described be given full 
consideration by those adopting this method of feeding. 



CHAPTER IV. 

MILK DILUTIONS WITH THE ADDITION 
OF CARBOHYDRATES. 

It has been our experience that about 90 per cent, of 
the infants that come under our observation for artificial 
feeding will tolerate a wide range of quantitative values 
in the components of the milk, i.e., fats, proteins, carbo- 
hydrates, and salts'. And the simpler the first formula 
on which the baby is started, the easier we find it to 
meet its later needs for growth and development, by in-, 
creasing or decreasing the individual elements in the diet. 
The first step of this method consists in the dilution of 
whole milk with water, thereby reducing all the ingredi- 
ents of the milk. When we compare such a dilution with 
human milk we find that when protein approximates that 
contained in breast milk, the fat is considerably reduced 
below that contained in the latter. This in practical feed- 
ing we find to be an advantage rather than a disadvan^ 
tage, and if there be an indication for increasing the fat 
content of the formula this is easily accomplished by the 
addition of cream, or top milk, which is, however, usu- 
ally not necessary, as the deficiency in fat can usually be 
successfully compensated by adding sugar and starch 
to the formula. As a result of dilution, the salts, which 
are about three times as great in quantity in cow's milk, 
are reduced to more nearly the amounts contained in 
breast milk. We must, however, remember that there are 
qualitative differences in the salt content of the cow's 
milk dilution and human milk (page 144). 

Feeding should primarily be formulated to promote 
normal growth and development, to supply energy for the 
body functions, to prevent disease ; and, although of no 
lesser importance, feeding in disease should be given a 
secondary consideration in the study of this subject. 

(119) 



120 INFANT FEEDING. 

The food must be given in such form that the infant 
may be able to digest it easily, to assimilate it, and 
to utilize its constituents for the purposes enumerated 
above. 

The following factors must be considered before esti- 
mating the composition and quantity of food for infant 
feeding. 

1. The clinical aspects — that is, the general well- 
being of the infant — must be given equal importance 
with the percentage and energy value of the food 
administered. 

2. Is there a normal gain in weight which an infant 
must show as a sign of full health ? 

3. The qualitative and quantitative chemical composi- 
tion of the food, the number of calories available from 
the total administered, and the proportion of the total 
fixated in the body must be taken into calculation. 

The normal artificially fed infant should manifest the 
same clinical evidences of good health and progress as 
are seen in the breast-fed infant. It should be com- 
fortable, which he manifests in a happy disposition. He 
should be a good sleeper, and awaken regularly for his 
feedings, and there should be no more occasion for his 
crying than in the case of the breast-fed baby. His tem- 
perature should show maximum excursions of 1° to 2° F. 
daily. He should have large quantities of subcutaneous 
fat, and his muscular tissue should be well developed. 
The turgor of his tissues should be normal. The latter 
can be estimated by the eye and by palpation. The 
muscles may be taken between the fingers, and their firm- 
ness or softness estimated in this way. By raising a fold 
of the skin we may determine whether the panniculus 
adiposus is well developed. The stools, which of neces- 
sity must vary with the diet, are firmer and drier and 
much paler than those of the breast-fed infant, and he 
should pass one or two daily. Except in the presence of 
large amounts of carbohydrates, and more especially malt 



MILK DILUTIONS WITH CARBOHYDRATES. 121 

sugars, they are alkaline in reaction, and have a foul 
odor. 

Therefore, we see that the criterion of good health for 
the artificially fed infant depends on many things, 
which together make up the condition of the infant. And 
we again desire to emphasize that the impression of the 
general well-being of the infant is a much safer method 
of estimating its progress than a study of his weight- 
curve alone. 




Fig. 8. — Scale for weighing infants. 

We have learned to recognize the study of the infant's 
weight as one of the simplest and most reliable clinical 
factors in estimation of the infant's progress. And while 
of necessity the diet of different infants necessary to 
normal weight increases must vary within very consider- 
able limits, the scale offers information which is of in- 
estimable value. 

The following may be taken as working averages for 
comparative purposes, and the estimation of over- and 
under- weight in infants coming under observation. 

Average weight at birth 7 pounds (3200 Gm.) 

Average initial loss 10 ounces (300 Gm.) or about one-tenth 

of the body weight at birth. 
Birth weight regained usually by the fourteenth day. 



122 INFANT FEEDING. 

Weight is doubled at the end of the fifth month. 

Trebled at the end of the first year. 

Average weekly gain during the first five months should 

approximate 5 ounces (150 Gm.), during the remainder 

of first year 4 ounces (120 Gm.). 
Yearly gain during the second year 6 pounds (2727 Gm.). 
Gain during the third year 4.5 pounds (2000 Gm.). 
Gain from the fourth to the eighth year, 4 pounds annually 

(1800 Gm.). 
Gain from the eighth to the eleventh year, 6 pounds annually 

(2700 Gm.). 

An accurate scale is a necessary equipment for proper 
infant feeding. Parents should be encouraged to pur- 
chase a balance scale with a large scoop. 

However, it. is not sufficient to base the determination 
of the amount of food on the weight of the baby alone, 
since two infants of the same weight may have decidedly 
different nutritional requirements, dependent upon vari- 
ous factors. The fat baby requires less food per pound 
than the thin baby — the overfed less than the underfed 
infant; and the sick baby must of necessity be fed within 
its limits of tolerance during the acute part of its illness, 
and the body losses must be compensated by increases in 
the diet beyond those which we have learned to consider 
as the normal feedings per pound body weight, as its 
tolerance for food permits during convalescence. 

A healthy infant should, therefore, show a regular gain 
within certain limitations. It is not absolutely necessary 
for an infant to add to its body weight every day, as daily 
irregularities are rather the rule than the exception. The 
relation of the time of weighing to the feeding, defeca- 
tion, and urination are factors which must always be 
taken into consideration. Therefore under normal condi- 
tions it is sufficient to weigh the infant once a week. It 
is especially wise to impress this upon a nervous mother. 

Further, we must not forget that the weight curve of 
the nursing infant and that of the artificially fed infant 
differ widely, so that they cannot be compared directly. 



MILK DILUTIONS WITH CARBOHYDRATES. 123 

The artificially fed infant, although in the beginning 
gaining less than the breast-fed infant, in the course of a 
year reaches the same weight as the breast-fed infant, 
who at first showed larger gains, but later lagged some- 
what in its gains. Much more important than the weight 
itself is the rising series of successive weight figures. 

The clinical aspects, that is, the general well-being of 
the infant must be given equal importance with the per- 
centage and energy value of the formula. In a consider- 
ation of the latter two important factors in successful 
feeding, the chemical composition must be considered of 
equal importance with the caloric value. Otherwise one 
meets with profound disturbances due to feeding of in- 
sufficient or excessive amounts of the components of the 
diet, difficult of interpretation. 

It may therefore be stated that the infant must be fed 
amounts of fat, protein, carbohydrates, and salts and 
water suitable to its constitution, age, and physical de- 
velopment, and that these ingredients should be in proper 
proportion and of sufficient quantity to meet the caloric 
requirements of its tissues for growth and development. 
Again, we must not overlook the fact that the constitu- 
ents of the diet must be in such form as to allow of nor- 
mal digestion and assimilation. 

We have spoken of the wide range of tolerance of in- 
fants to their foods, and have mentioned that this, in all 
probability, accounts to a very great degree for the fact 
that so many men have been successful in the feeding of 
infants on a variety of mixtures which varied greatly 
both quantitatively and qualitatively. There is in all 
probability another factor which is important in explain- 
ing these successes, namely, the fact that to a certain ex- 
tent fats, carbohydrates, and proteins are interchange- 
able in their metabolic functions. 

Proteins. After passing through the intestinal wall 
proteins have three functions to perform : (1) to replace 
used protein (lost through urine, sweat, digestive juices, 



124 INFANT FEED1XG. 

cell destruction, etc.) ; (2) to satisfy cell growth, which 
would be impossible without proteins; (3) to furnish 
fuel for part of the dynamic loss (fats and carbohydrates 
are the natural fuel, the protein combustion being 
incidental only). 

There is three times as much protein in cow's milk as 
in human milk. The reason for this is obvious, when 
we recall that the ratio of the growth of the calf to that 
of the infant is about as 2 to 1. Furthermore, the protein 
in cow's milk consists chiefly of casein (3.02 per cent.) 
and little lactalbumin (0.53 per cent.), while human milk 
contains 0.59 per cent, of casein and 1.23 per cent, of 
lactalbumin. 

The proteins are characterized by containing nitrogen. 
If the nitrogen is determined in the food eaten during the 
period of the experiment, it is evident that a balance may 
be struck which will determine whether the body is re- 
ceiving in the food as much protein nitrogen as it is 
metabolizing and eliminating in the excreta. If there is 
a plus balance in favor of the food, it is evident that the 
body is laying on or storing protein, while if the balance 
is minus, the body must be losing protein. During the 
period of growth, in convalescence, etc., the body does 
store protein, and under these conditions the balance is in 
favor of the food nitrogen. 

It is important also to bear in mind that nitrogen or 
protein equilibrium may be established at different levels 
in order to explain the good feeding results with what 
may be an excessive protein diet. That is, an infant who 
has been receiving 1.5 Gm. of protein per Kg., and who 
has excreted the greater part thereof, retaining only such 
portion as is needed for the body growth, will, upon 
being fed larger quantities, retain only a similar amount 
for body growth, excreting the difference in the urine, 
sweat, and feces. The true cell life does not depend on 
what has been ingested, absorbed and temporarily fixated, 
to be eliminated soon afterwards, but on the constant and 



MILK DILUTIONS WITH CARBOHYDRATES. 125 

stable fixation. The body may become adapted to over- 
feeding and overfixation, but this is usually of only a 
short duration, and the excretion of the oversupply is 
never long delayed. Experimentally, it is found that 
there is a certain low limit of protein which just suffices 
to maintain nitrogen equilibrium. Rubner found that 
when 5 per cent, of the total energy intake was in protein 
that it was sufficient for maintenance, and that even 4 
per cent, was sufficient to supply its actual need when 
amply supplied with carbohydrate. However, 7 per cent, 
was necessary to keep up the normal growth. 

Examination of the dietaries of civilized races shows 
that, on the average, 100 to 120 Gm. of protein are used 
daily by an adult man. A variable portion of this amount 
passes into feces in undigested form, but we may assume 
that about 100 to 105 Gm. are absorbed, and actually 
metabolized in the body. If we take into account the 
weight of the body, this amount of protein may be esti- 
mated as equivalent in round number to 1.5 Gm. of pro- 
tein, or 0.23 Gm. nitrogen, per kilogram of body weight. 
Chittenden believes that the daily quota of protein per 
kilogram of body weight may be reduced to one-half this 
quantity, from 1.5 Gm. to 0.75 Gm. of protein, or 0.12 
Gm. of nitrogen, per kilogram body weight. 

If the body can be kept in good condition upon 0.75 
Gm. per kilogram per day, will an ingestion of more than 
this (say twice as much) prove injurious or beneficial or 
indifferent to the body? The full and satisfactory 
answer to this question must be deferred until more ex- 
perience is obtained. The newer conceptions in regard 
to the digestion and nutritive history of the protein foods 
seem to favor the adoption of a low protein diet. 
Mankind, when left to the guidance of the natural appe- 
tites, has always, when possible, adopted the high pro- 
tein level of 90 to 100 Gm. per day. That mankind has 
made a mistake in adopting the higher protein level can 
hardly be claimed on the basis of our present knowledge. 



126 INFANT FEEDING. 

The chief demands for protein are to compensate for 
wear and tear, and to provide for growth. 

Sugars and starches, when added to a diet sufficient to 
meet an infant's needs, will, temporarily at least, cause 
a greater nitrogen retention. Fats have little or no such 
influence. Nitrogen to be retained must be built up into 
living protoplasm, and to accomplish this salts must be 
available. Unless they are present, the nitrogen is again 
excreted. Approximately 1.7 Gm. of ash are retained 
for each 1 Gm. of nitrogen (Howland), or 0.3 Gm. of 
ash for each 1 Gm. of protein. 

Hoobler believes that the protein needs of the infant 
are supplied when 7 per cent, of its caloric needs is fur- 
nished in protein calories, and states that three-fourths of 
an ounce of whole or skim milk, or 1.3 Gm. of protein 
per kilogram (0.6 Gm. per pound) body weight is 
sufficient to meet these needs. To make up the deficiency 
in the caloric needs, he adds for each ounce of whole 
milk one-third of an ounce of sugar or cereal. 

Rubner was able to promote normal growth when 0.7 
per cent, of the total energy intake was in proteins. 

Cowie finds the protein requirement in a two- to 
twelve-months infant to average 2.4 Gm. per kilogram 
(1.1 Gm. per pound). 

Dunn states that 1.0 Gm. to 1.5 Gm. of protein daily 
per kilogram (.45-. 7 Gm. per pound) of body weight is 
necessary for the normal infant. 

Camerer states the following requirements for each 
kilogram of body weight in a child between 2 and 4 
years of age: proteins, 3.6 Gm. ; fat, 3.1 Gm. ; carbohy- 
drates, 9.2 Gm. ; and water, 75.3 Gm. 

It has been our custom to feed approximately 7.5 
ounces of milk to a pound of body weight to the healthy 
normal infant, which would represent 7.5 Gm. of protein 
per pound of body weight. (3.3 Gm. per kilogram.} 

Notwithstanding what has been said on theoretical and 
experimental studies of the protein needs of the arti- 



MILK DILUTIONS WITH CARBOHYDRATES. 127 

ficially fed infant as compared with the amount of pro- 
tein as received by the breast-fed infant, it must be 
granted that casein, the chief protein of cow's milk, as 
given in ordinary dilutions to the infants is sufficient to 
cover entirely the protein needs of the infant, and that 
its excess rarely causes nutritional disturbances when 
the tendency to large curd formation is prevented by 
boiling or alkalinizing the milk. 

We have therefore continued to use the protein as 
contained in 1.5 ounces of milk per each pound of body 
weight of the normal infant, and in the underfed we 
have not hesitated to increase this quantity to an amount 
equal to 2 or even 2.5 ounces per pound, thereby approxi- 
mating 1.5 ounces per pound of what the baby should 
weigh for its age. Increases of milk in the diet must be 
gradual, the additions being guided by the child's ability 
to handle the food. From what has been stated, it may 
be inferred that it is wise to establish the protein content 
in a diet which may then be supplemented by fats, carbo- 
hydrates, and salts, because protein is the tissue builder 
and must necessarily be a basic constituent of all diets. 

Fats. Fats are necessary to normal growth and 
nutrition of the human body. But they to a greater ex- 
tent than the other food elements can be replaced by 
proteins and sugars, more especially the latter. This ex- 
plains the fact that infants fed on low fat mixtures, more 
especially proprietary foods, such as condensed milk, will 
continue to gain in weight. However, such development 
cannot be considered as normal. 

Fats furnish part of the heat energy necessary to main- 
tain the body temperature. They are stored as a reserve 
food. The fat is a protein saver, and when supplied in 
proper amount but little protein is used for the produc- 
tion of animal heat, thereby allowing for greater protein 
retention for the growth of the body tissues. 

Under normal conditions, the average infant will digest 
from 2 to 3.5 per cent, of fats. However, some infants 



128 INFANT FEEDING. 

digest fat badly, and when a fat intolerance is once estab- 
lished it is overcome only with great difficulty. In such 
cases it is necessary to throw the burden of furnishing 
the extra food necessary on the carbohydrates; and car- 
bohydrates in large quantities are unsafe food for the 
infant. Such a catastrophe should be avoided, as infants 
receiving an insufficient amount of fat rarely thrive satis- 
factorily. We should therefore aim to stay within safe 
limits. And it has been our experience that most infants 
will thrive well on the amount of fat furnished by the 
use of 1.5 to 2.0 ounces of whole milk per pound body 
weight. When moderate quantities of fat are fed, we 
avoid the acute clinical picture of fat overfeeding asso- 
ciated with vomiting and diarrhea, and not infrequently a 
high temperature, and occasionally convulsions. On the 
other hand, the moderate quantity of fat contained in the 
diet necessitates a high percentage of carbohydrate feed- 
ing, which in turn avoids the so-called fat-soap stools, 
with their tendency to rob the body of an excessive 
amount of calcium and magnesium. For the formation 
of a fat-soap stool it is necessary that we have an insuffi- 
ciency of carbohydrates and a relative excess of proteins, 
as putrefaction is necessary for the production of these 
stools, while fermentation opposes their formation. And 
in the presence of excessive fermentation the putrefac- 
tion is limited. 

It may therefore be stated that while the tolerance for 
fat of cow's milk varies greatly in different individuals, 
most infants, however, will digest and assimilate 1.5 to 
2.0 Gm. of fat per pound body weight daily, (3.3-4.4 Gm. 
per kilogram) which is the quantity represented in 1.25 
to 2.00 ounces of average cow's milk. This quantity will 
also supply the body needs for growth and development, 
when associated with a sufficient carbohydrate. 

Carbohydrates. They are used chiefly to supply 
heat and energy, to supply in part material for fat foun- 
dation, thereby replacing in part the fat waste. Because 



MILK DILUTIONS WITH CARBOHYDRATES. 129 

of their high caloric value they supply a large amount of 
energy. They are efficient sparers of protein, and will 
supply energy in case of fat insufficiency in the diet. 
Synthetically, they are converted into glycogen in the 
body. Fat is formed from sugar by the subcutaneous 
cells, which are especially adapted to this function. 
Sugar is reduced to C0 2 and water, which may be meas- 
ured by the respiratory metabolism. Normally, sugar is 
absorbed from the small intestine in greater part, and is 
not found in the feces. If absorbed in sufficient quantity, 
they will cause a rapid increase in weight. When insuffi- 
cient carbohydrate is supplied to the body, it is obtained 
by breaking down the body protein. 

In general, infants have a very high carbohydrate tol- 
erance — much higher than the adult — and even infants 
suffering from certain forms of nutritional disturbance 
may retain their ability to metabolize sugar, even though 
it may have been reduced for fat and proteins. Some 
infants do not handle sugar well, and among these 
certain forms of gastro-intestinal disturbances, eczema, 
etc., are of frequent occurrence. 

During recent years much has been written on the 
superiority of one form of carbohydrate over the other. 
We can practically exclude the monosaccharides in the 
consideration of the subject, and speak only of the di- 
saccharides, of which lactose, saccharose (cane-sugar), 
and maltose are the ones used in infant feeding, of the 
polysaccharides, as represented by the cereal flours and 
dextrin, and last, of the mixture of disaccharides and 
polysaccharides, together with other substances, these 
mixtures being represented by the various infant foods 
on the market. 

// Cane and Milk Sugars. Of recent years there has 
been a considerable discussion on the comparative nutri- 
tive value of milk-sugar (lactose) and cane-sugar 
(saccharose). In our own experience we have found little 
to recommend one over the other in so far as their 

9 



130 INFANT FEEDING. 

nutritive value and the limit of tolerance is concerned, 
except as we have seen a laxative effect from the use 
of lactose, which is usually not present with the same 
quantities by weight of saccharose. This is, however, 
not seen in all infants. Cane sugar will answer the needs 
of most infants. For practical purposes the following 
quantities of sugar in addition to that contained in the 
milk will meet the carbohydrate requirements. 

1. Normal full weight infants one-tenth ounce by 
weight of sugar for each pound of body weight (3 grams 
for each pound). 

One and one-half ounces of milk contain 2 Gm. making 
a total of 5 Gm. to the pound or 11 to the kilogram. Holt 1 
and Fales found that nursing infants took on the average 
12 Gm. carbohydrate per kilogram daily; artificially fed 
infants somewhat more than this. They suggest that an 
infant of average activity at one year be allowed about 
12 Gm. per kilogram decreasing the amount to about 
10 Gm. at 6 years. 

Carbohydrate needs beyond that furnished by one and 
one-half ounces of sugar should be supplied by well 
cooked cereal waters, because of the danger of sugar 
indigestion. (See mixed diet, page 145.) 

The total carbohydrates (sugar contained in the milk, 
sugar added to the milk, and cereal, if used), should 
average from one-eighth to one-fifth ounces, (4 to 6 
grams) per pound body weight a day. One and one- 
half ounces of milk, averaging 4.5 per cent, carbohydrate 
furnishes 2 grams of lactose. 

2. In underweight infants the amount of sugar to be 
added must frequently be calculated on the basis of 
the normal average weight of the healthy infant of 
the same age. (See page 143.) 

Precautions to be Heeded in the Addition of Carbo- 
hydrates to the Infant's Diet: 

1. Infants who have been on a low sugar diet should 



1 Holt, L. E. and Fales, H L. : Am. J. Dis. of Children ; xxiv, 
44, 1922. 



MILK DILUTIONS WITH CARBOHYDRATES. 131 

be accustomed to the change by gradual increase of the 
sugar content of their food. 

2. In underweight infants the amount of sugar to 
start with should be calculated on the basis of their 
present weight. The quantity of sugar needed for a 
full weight infant of the same age should then be ap- 
proximated as rapidly as the sugar tolerance permits. 

3. In changing from one kind of sugar to another, it 
is always a safe rule to reduce the quantity for a few 
days, further increases being governed by the infant's 
tolerance. 

4. It should be remembered that in some infants the 
disaccharides when fed in full amounts are liable to 
produce digestive disturbances. In these infants the 
sugar in part at least must be replaced by polysaccharides 
in the form of cereal flours and cereals. 

Maltose and Dextrin Compounds can frequently be 
added to the diet to advantage in the presence of sta- 
tionary weight, because they can be added to the mix- 
ture in quantities approximating one-eighth of an ounce 
(4 grams) for every pound normal weight, when indi- 
cated. It must, however, be remembered that their 
action on the bowels varies greatly depending upon their 
maltose, dextrin and alkali content. Thus we find that 
those of the proprietary foods containing a considerable 
percentage of dextrin, in the absence of the potassium 
salt, are constipating (Mead's dextrimaltose No. 1 and 
No. 2), while those with .a higher maltose content to- 
gether with potassium carbonate (Borcherdt's dri malt 
soup and Mead's Dextrimaltose No. 3) or with potas- 
sium bicarbonate (Mellin's Food and Horlick's Malt 
Food) are laxative. 

Cereal Flours. They can be added to the diet of 
most infants early in life in quantities varying from 0.5 
to 1.0 Gm. (%o to V.u) ounce) of flour for each pound 
of body weight. Such an addition to the food fre- 
quently results in rapid weight increases, and general 



132 INFANT FEEDING. 

improvement of the infant. In older infants, cooked 
cereals may be used in place of the starch solutions. We 
have reason to believe from clinical experience that the 
flours made from unheated cereals have a decided advan- 
tage over the dextrinized flours on the market. Whether 
this is due to vitamines and vegetable proteins contained 
in the former or to some other distinctive property we 
are unable to state. The cereals also have a decided 
influence on the calcium and magnesium balance. The 
cereals cause retention of these salts, which may have 
a favorable influence on the weight. 

Salts. Salts are necessary in digestion, and in every 
step of metabolism, from absorption to excretion and 
secretion. The role of salts in both normal and path- 
ological conditions has been given constantly increasing 
importance in the last few years. 

Human milk contains 0.2 Gm. of ash in 100 mils, and 
cow's milk 0.75 Gm. of ash in 100 mils. The difference 
in percentage in the human and in the cow's milk is 
equalized by the body using only what is necessary for its 
life and growth. The salts are absolutely necessary for 
the life of the organism. 

All the salts except those of iron are found in larger 
amounts in whole cow's milk than in human milk. In 
general, cow's milk contains relatively a very large 
amount of calcium phosphate, while the proportion of iron 
in cow's milk as compared with human milk is relatively 
small. There is a great difference in the form in which 
phosphorus is present in human and in cow's milk. In 
human milk three-quarters of the phosphorus is in or- 
ganic combination, while in cow's milk only one-quarter 
is in organic combination. The iron in neither human 
milk nor in cow's milk is sufficient to meet the demands 
in the first year of life; the infant must in part depend 
on the iron stored during fetal life. 

The following table gives the percentages of different 
salts in 100 parts of ash of human and cow's milk. 



MILK DILUTIONS WITH CARBOHYDRATES. 133 





CaO 


MgO 


P 2 5 


Na 2 


K 2 


Cl 


Fe 


Human milk . . 


.. 23.3 


3.7 


16.6 


8.0 


28.3 


16.5 


.00015 i 


Cow's milk 


.. 23.5 


2.8 


26.5 


7.2 


24.9 


13.6 


.00007 » 



Grams of salts per 100 c.c, of milk. 

CaO MgO P 2 5 Na 2 K 2 Cl Fe 

Human milk .. .0458 .0074 .0345 .0132 .0609 .0358 .000171 
Cow's milk 172 .02 .2437 .0465 .1885 .082 .00007 2 

In all the constituents except P2O5 and iron, the per- 
centages of the different salts in the two milks are prac- 
tically the same. The higher proportion of phosphorus 
in cow's milk is due to the large amount of the casein. 
Though the proportions of the different salts of the 
ash in cow's milk are so nearly those of human milk, the 
amount in cow's milk is about three and a half times 
as great. Unless, therefore, cow's milk has been diluted 
with more than twice its volume, the amount of these 
inorganic constituents furnished to the infant is equal 
to that which he receives in human milk (Holt). 
Human milk contains about twice as much iron as cow's 
milk, and dilution of cow's milk results in a decrease 
in the iron content, which must not be carried too far 
unless supplemented by other iron-containing food. 

The infant receiving undiluted cow's milk, with its 
greater salt content, lives on a higher plane of mineral 
metabolism than does the one receiving the breast milk. 
He absorbs 60 per cent, of the total ash, and retains only 
about 15 per cent., while the breast-fed infant utilizes to 
the full his opportunities, and absorbs 80 per cent, of 
the ash, and retains 40 to 50 per cent. In the majority 
of infants this excessive salt intake undoubtedly does no 
harm ; the surplus is not absorbed, or is merely eliminated. 

"Sodium and potassium are usually well retained, un- 
less severe diarrhea is present, or there is an excess of 
fat or of sugar in the diet. Under such circumstances 



■Holf: Amer. Jour, of Dis. of Child., Vol. x, 1915. 
2 Langstein-Meyer : Weisbaden, Verlag von J. F. Bergman, 
1914, p. 22. 



134 INFANT FEEDING. 

they are lost, and the loss is badly borne, and cannot in- 
definitely be continued. When all available alkalies have 
been drawn on, the infant breaks down his own tissue 
to furnish more of these substances, which is an explana- 
tion, for a part at least, of the excessive nitrogen excre- 
tion under such conditions. When diarrhea ceases, and 
the intake is sufficient, a positive balance is rapidly 
instituted. 

"The metabolism of calcium has been largely studied, 
on account of its close relationship to rickets and tetany. 
Calcium is so largely excreted by the bowel that it is im- 
possible to say how much is absorbed, plays part in the 
organism, and is then excreted by the intestine and urine, 
either because it is in excess, or because ( as in the case 
of rickets) the body cannot utilize it. This is also true 
of magnesium, and to a much less extent of sodium and 
potassium" (Howland). 

The salts are necessary for building up of the body tis- 
sue, and each gram of protein retained and built into 
body tissue requires approximately one-third of a gram 
of ash. 

Water. The quantity of water necessary for the in- 
fant is not only of theoretical, but also of vast practical 
importance. There are many breast-fed infants who ob- 
tain a food which is very rich in other nutritive sub- 
stances, but contains only a small amount of water. 
These infants may not gain well in weight unless water 
is added. And, besides, in sick infants it is occasionally 
necessary to feed them (especially in cases of vomiting, 
anorexia, infections) with concentrated food, and in these 
cases the total water intake necessary must not be lost 
sight of. 

The lack of or inadequacy of water is much more dan- 
gerous to the infant than a corresponding deficiency in 
the food. 

Water to be Added. The most important fact to re- 
member is that young infants require a minimum of one- 



MILK DILUTIONS WITH CARBOHYDRATES. 135 

fifth of their body weight in water daily (3 ounces per 
pound) and in their later months at least one sixth of 
their body weight (2 l / 2 ounces per pound). 

Water may be given twice daily from a bottle in 
quantity sufficient to meet the infant's requirements by 
feeding the difference between one-fifth of the body 
weight and the milk mixture. (A ten pound baby should 
get 30 ounces of fluid. If receiving 25 ounces of milk 
mixture, a daily total of 5 ounces of water may be given 
from a bottle between feedings.) 

If the infant shows a desire for larger individual meals 
than are furnished by following the amounts outlined, the 
total fluids (milk and diluent) can be figured on the basis 
of 3 ounces to the pound and the additional water re- 
quired to meet the total day's fluid may be added to the 
mixture in place of being given between meals. 

Estimation of the Caloric Contents of the Food as a 
Check on Over- and Under- feeding. Calorimetric 
estimations of the diet must be considered only as a check 
on under- and over- feeding, and not as a method of 
feeding. In the infant whose diet usually consists of 
milk or its constituents and sugar and cereal flours, this 
is a very simple matter. It should, however, be remem- 
bered that there are considerable variations in the caloric 
requirements of normal babies. The fat and well-nour- 
ished infant will require less food to maintain its body 
heat than the emaciated one. The sick baby will rarely 
be able to digest its full needs as estimated by its body 
weight. Therefore as in every other phase of infant 
feeding, the individual infant must be given primary 
consideration. It must be remembered that the nutri- 
tion of the baby depends upon the quantity of the food 
assimilated, and not upon the quantity ingested. Less 
food is being absorbed and utilized in the infant with a 
deficient power of digestion, and overfeeding will re- 
tard the infant's progress. A comparative estimate of 
the infant's diet, with a theoretical minimum, is of special 



136 INFANT FEEDING. 

value in cases of doubt as to whether the retarded prog- 
ress is due to insufficient food or defective digestion and 
assimilation. 

Under this system the physician reckons the minimum 
daily caloric requirements, either from the present 
weight of the baby or what it should weigh in health, 
and then chooses the food necessary to meet this re- 
quirement, bearing in mind that the fat, carbohydrate and 
protein contents of the diet must not only meet the 
caloric requirements, but also be properly proportioned, 
so as to contain the proper number of grams of each of 
the constituents to meet the infant's needs for growth 
and development. 

Heubner and Rubner gave us the first definite estimates 
as to the caloric needs. They found that the average 
healthy infant after birth requires on the average 100 
calories per kilogram body weight, from six months to 
the end of the first year — approximately 85 calories per 
kilogram body weight — and that 70 calories per kilogram 
body weight is the energy quotient on which a baby would 
maintain a weight equilibrium. 

Dunn places this minimum caloric requirement for 
artificially fed infants as follows : 

Birth to 6 months . . . 120 cal. per Kg. (55 cal. per pound) 

6 to 12 months 100 " " " (45 " " " ) 

12 to 24 months 90 " " " (40 " " " ) 

Dennett 1 gives the following figures : 

Fat infants over 4 months of age .. 40 to 45 cal. per pound 
Average infants under 4 months of 

age and moderately thin infants of 

any age 50 " 55 " " " 

Emaciated infants (varying with the 

degree of emaciation) 60 "65 " " " 



1 Infant Feeding, J. B. Lippincott Co., Philadelphia, page 58. 



MILK DILUTIONS WITH CARBOHYDRATES. 137 

Brady 1 gives the following figures as his experience 
with institutional children: 50 to 55 calories for each 
pound during the first 6 to 8 months of life. 

Our own experience coincides with those of Dennett 
and Brady in that we find that the figures of Heubner do 
not meet the requirements of any except the well-nour- 
ished infants. Underfed infants not suffering from de- 
composition (marasmus) must be fed food of a higher 
caloric value per pound body weight than the normal in- 
fants, and while such infants must be fed minimal quan- 
tities when first seen, for a proper gain in weight their 
normal weight must be estimated and their diet gradually 
approximated to the needs of the weight that they should 
normally have. 

Average infants under 

2 months of age .. 30 to 45 cal. per ft ( 65 to 100 per Kg.) 
Average infants over 

2 months of age ..45 " 55 " " " (100 " 120 " " ) 
Premature and thin 

in f ants under 2 

months of age 50 to 65 cal. per ft (110 to 140 per Kg.) 

Thin infants older 

than 2 months, de- 
pending upon their 

general condition . 55 " 70 " " " (120 " 150 " " ) 

During the first few weeks of life of the artificially fed 
infant it is usually difficult to approximate these figures 
(see page 151). 

Increases in quantity of food should always be gradual, 
especially in the presence of malnutrition, and the infant 
carefully observed, and increases made only as the toler- 
ance for food permits. 

Estimation of the caloric contents of the food is not a 
feeding method and should be used only as a check on 
over- and under- feeding, the scale, stool, and general 



1 J. M. Brady, Institutional Care of Infants, Archives of 
Ped., 1917, 34, 356. 



138 INFANT FEEDING. 

condition, and particularly the disposition of the infant, 
being the ultimate guide for dietetic changes. 

Energy quotient is the number of calories which the 
infant is getting per pound or per kilogram of body 
weight. To determine the energy quotient of the diet 
multiply the number of ounces of each food ingredient of 
the food mixture by their caloric values, add the products 
and divide the sum by the number of pounds or kilo- 
grams of the baby's weight. 

Caloric Values of 1 oz. (30 Gm.) of Various Foods. 

Calories 

Cow's milk 21 

Human milk 21 

16 per cent, cream 54 

Skim milk 11 

Buttermilk 11 

Buttermilk mixture 21 

Albumin milk 12 

Chymogen milk 21 

Keller's malt soup 25 

Cane-sugar (by weight) 120 

Maltose-dextrin compounds (average) 110 

Malt-soup extract, dry, by weight 90 

' by measure 132 

Flour, by weight 100 

Cereal waters (1 oz. cereal to quart) 3 

PRACTICAL APPLICATION OF MILK DILUTIONS WITH ADDI- 
TION OF CARBOHYDRATES IN INFANT FEEDING. 

In the application of the rules for the feeding of normal, 
healthy infants, it must be remembered that each infant 
must be fed to meet its individual requirements, and the 
rules modified so as to meet the demands of the individual 
baby. If milk dilutions, with the addition of carbohy- 
drates are used, the simplest and most natural standard 
would be one that would tell us how much milk and car- 



Note : — 

1 gram of fat = 9.3 calories. 

1 " " protein = 4.1 

1 " carbohydrate ==4.1 " 



MILK DILUTIONS WITH CARBOHYDRATES. 139 

bohydrates per pound or per kilogram body weight the 
baby should get. To be exact we should express, or at 
least be aware, of the number of grams of proteins, fats, 
carbohydrates and salts that the infant is receiving for 
each pound of its body weight. We believe that if statis- 
tics on infant feeding were collected on this basis rather 
than in percentages of the ingredients in the milk mix- 
tures (the total mixture being of such variable quantity) 
the collected data would be far more valuable as a basis 
for future zuork in infant feeding. 

Data as to Foods and Food Requirements Used 
as a Basis for Estimating the Diet of Infants. 

Average cow's milk contains the following percentages : 

Fat 4.0 per cent. 

Protein 3.5 

Carbohydrates 4.5 

CaO 0.172 

Grams of food elements needed as a minimum by the 
average artificially fed normal infant in twenty-four 
hours : 

Per Pound. Per Kilo. 

Fat 1.5 to 2.0 3.3 to 4.4 

Protein 1.5 3.3 

Carbohydrates 5.0 11.0 

CaO 0.08 0.17 

Water 90.0 200.0 

The milk or cream and skim milk needed to supply fat 
and protein will average 2 grams of sugar so it will be 
necessary to add amount needed in excess of this % 
ounce or (3 grams) per pound or 6.6 per kilo. 

For each gram of food elements in the mixture the fol- 
lowing ingredients must be added : 

Fat 7io ounce or 6 mils of cream. 

% ounce or 25 mils of milk. 
Protein 1.0 ounce or 30 mils of milk 

or skim milk. 

Carbohydrates r .-;o ounce or 1 Gm. of sugar. 

CaO 18.S ounces or 600 mils of 

milk or skim milk. 



140 INFANT FEEDING. 

For each pound of body weight the following will be 
required : 

Fat (1.5 to 2 Gm.) %o to fio ounce or 9 to 12 

mils of cream. 
134 to 1% ounces or 37.5 to 
50 mils of milk. 

Protein (1.5 Gm.) \ l / 2 ounces or 45 mils of milk 

or skim milk. 
Carbohydrates (3 Gm.) .. Ho ounce or 3 Gm. of sugar. 

CaO (0.08 Gm.) V/ 2 om -es or 45 mils of milk 

or skim milk. 

For each kilogram of body weight the following will be 
required : 

Fat (3.3 to 4.4 Gm.) 20 to 27 mils of cream. 

85 to 110 mils of milk (aver- 
age 100 mils). 

Protein (3.3 Gm.) 95 mils (milk or skim milk). 

100 mils in round figures. 
Carbohydrates (6.6 Gm.) . . 6.6 Gm. of sugar. 
CaO (0.172 Gm.) 100 mils in round figures. 

No allowance has been made for protein in cream. 

Protein figured at 3.5 per cent, in milk. 

Therefore to meet protein and fat requirements in feed- 
ing with diluted whole milk, the average normal infant 
will require each day a minimum of \]/ 2 ounces (45 mils) 
per pound or 100 mils per kilo of body weight, exclusive 
of the sugar and starch which are added in preparation 
of the mixture. 

Practical experience has taught us that infants under 
five months of age will frequently require amounts ap- 
proximating 2 ounces (60 mils) of cow's milk per pound 
body weight, except during the first few weeks of life, 
when smaller quantities of whole or skim milk are indi- 
cated (see page 151 ). With the institution of a mixed diet, 
the infant thrives with less milk per pound body weight. 

In beginning feeding with cow's milk, mixtures must 
always be started as weak formula?, more often using 
only 1 ounce (30 mils) of cow's milk to a pound bodv 



MILK DILUTIONS WITH CARBOHYDRATES. 141 

weight, gradually increasing the strength to meet the 
infant's needs. 

Underweight infants should at first be fed according 
to their present weight, gradually increasing the strength 
of the mixture as rapidly as consistent with the baby's 
ability to handle the diet, and thus approximating the 
needs of a full weight baby of the same age. These 
babies will frequently take over 2 ounces (60 mils) of 
milk per pound body weight. 

Number of Feedings in Twenty-four Hours. Three- 
hour intervals at the start, with 7 feedings in twenty- 
four hours, for the first month (6-9-12-3-6-10-2), 6 feed- 
ings during the second and the third month (6-9-12-3- 
6-10), 5 feedings by the fourth to the fifth months (6-10- 
2-6-10), according to the individual needs of the child. 

Premature and delicate infants with a tendency to 
vomit are exceptions, and may be fed smaller amounts at 
more frequent intervals, even two hours, if indicated. 
Catheter feeding may be necessary, in which case the 
longer interval will usually answer. 

Amounts at Each Feeding. On 3-hour intervals the 
quantity should be one ounce more than baby is months 
old. Example: A 3-months-old baby takes four ounces 
per feeding if fed every three hours. 

On four-hour intervals, the quantity is two ounces 
more than the baby is months old. Example : A 6- 
months-old baby takes eight ounces per feeding on a four- 
hour schedule. 

The increases per feeding are made gradually until the 
feedings reach eight ounces. 

Exceptionally, infants cannot take this amount at each 
feeding, and when vomiting is the result of overfeeding, 
the quantity can be reduced and an extra meal sub- 
stituted. Some infants will demand larger feedings. 

After the fourth month the average infant will take 
daily 1 quart of the food mixture. 



142 INFANT FEEDING. 

By the sixth month four meals of 8 ounces each of 
milk mixture may be given, and a fifth meal of broth 
and vegetables (sec rules for mixed diet, page 14-5). 

Water to be Added. In our own experience we have 
found that a concentrated milk mixture does not disturb 
the infant's digestion when the milk is boiled or alkalin- 
ized by sodium citrate, sodium bicarbonate, or lime- 
water. The amount of water is calculated by multiplying 
the number of feedings by the amount of each feeding, 
and subtracting the milk to be given. 

Example: Baby aged 3 months should receive 5 feed- 
ings, 5 ounces each (age in months plus 2) or a total of 
25 ounces for the day. Subtracting 16.5 ounces (11 
pounds body weight and 1.5 ounces of milk for each 
pound) gives us 8.5 ounces as amount of water to be added. 

The total fluids for the day should equal at least one- 
sixth the body weight. If the mixture does not total this 
amount sufficient water can be fed between meals. 

Carbohydrates to be added. Having the necessary 
amount of milk and water, we ascertain the carbohy- 
drate to be added. 

Cane sugar answers our requirement for most cases. 

Milk sugar acts as a laxative in many infants. Unless 
the laxative effect is desirable, it has no advantages. 

Maltose and dextrin compounds are acceptable to the 
infant's digestion in relatively larger quantities. They 
are not as sweet as cane sugar. They are of practical 
value when large amounts of cane or milk are not well 
taken. Because of their varying maltose, dextrin and 
alkali content some are constipating and others are 
laxative. This must be given due consideration in their 
selection (see page 131, also see Appendix). 
' Cane and milk sugar are added in such quantities that 
the normal infant in its food mixture receives a total of 
from 4 to 6 grams of carbohydrates per pound of body 
weight per day, including that contained in the milk in 
the mixture. As one and one-half ounces of milk con- 



MILK DILUTIONS WITH CARBOHYDRATES. 143 

tains approximately 2 grams of lactose it will be neces- 
sary to add from 2 to 4 grams of carbohydrates for 
each pound of body weight to the diet besides that con- 
tained in the milk. The needs of the average normal 
infant in the first months are usually satisfied by the 
addition of one-tenth of an ounce (3 grams) of cane 
sugar per pound body weight to the milk and the water 
in the mixture. 

When using maltose-dextrin compounds somewhat 
larger quantities can often be fed to advantage. One- 
eighth ounce (4 grams) per pound are usually well taken. 

We do not hesitate to add cereal water to the diet 
after the infant is one month old, and find it especially 
valuable in those cases in which we are feeding cane- 
sugar, and in which the infant takes a dislike to its food 
because of the intense sweetness of the mixture. One- 
sixtieth to one-thirtieth of an ounce (0.5 to 1.0 gram) 
of starch for each pound of body weight may be added 
to the mixture. This is best given in the form of cereal 
waters or well cooked cereals. 

In underweight infants the amount of sugar to start 
with should be calculated on the basis of the present 
weight, approximating the quantity needed for a full 
weight infant as rapidly as the sugar tolerance permits. 

The following table gives equivalents of 1 ounce by 
weight and the domestic measures of carbohydrates used 
in artificial feeding- of infants: 





By 


By Table- 


Dessert- 


Tea- 




weight 


measure spoonfuls 


spoonfuls spoonfuls 








level 


:d with a knife. 


Cane-sugar 


. 1 oz. 30 Gms. 1.00 oz. 


2 


3 


6 


Milk-sugar . . . 


. 1 " " 


1.50 " 


3 


4.5 


9 


Maltose-dextrin 


. 1 " " 


1.50 " 


3 


4.5 


9 


Flour (wheat) 


. 1 " " 


2.25 " 


5 


7.5 


15 


Flour (barley) 


. 1 " " 


1.50 " 


3 


4.5 


9 


Barley (pearl) 


. 1 " " 


2.50 " 


5 


8 


15 


Oats (rolled) 


. 1 " " 


2.50 " 


5 


8 


15 


1 tablespoon 


ful = 1.5 dess 


ertspoon fuls 


= 3 


teaspoon f i 


Is. 



144 INFANT FEEDING. 

To Break the Curd to Assist Digestion of Cow's 
Milk. Many infants can digest raw cow's milk. When 
not well taken, the tendency to formation of large protein 
curds is relieved by boiling the milk 1 from two to three 
minutes over the flame, or, better, by putting in a double 
boiler and heating until the water in the outer vessel 
boils eight minutes. Although the curd is less finely 
divided by the use of the double boiler, as compared with 
boiling on the direct flame, it answers the purpose of 
most infants, and causes fewer changes in the milk. 

Addition of sodium citrate to the milk mixtures also 
prevents formation of hard protein curds. Bosworth and 
Van Slyke have shown that increasing amounts of sodium 
citrate added to the milk increases the coagulation time 
up to the point when 1.7 grains (0.1 Gm.) per ounce (30 
mils) is added, after which the milk does not coagulate 
at all. Sodium which is added replaces some of the cal- 
cium in the casemate, and forms calcium-sodium case- 
mate, and when rennin is added this double salt is 
changed to calcium-sodium-paracaseinate. which in the 
presence of sufficient quantity of sodium does not curdle. 
Sodium citrate may be prescribed either in 5-grain tab- 
lets, adding approximately 1 grain for each ounce of milk 
in the mixture, or a prescription may be written in such 
form that each teaspoon ful will contain sufficient sodium 
citrate for the day's food. 

When lime-water is added to cow's milk until it is 
neutral or faintly alkaline to phenolphthalein, a basic cal- 
cium casein is formed which is not acted upon by rennet, 
and will not form a curd, even in the presence of lime 
salts (Van Slyke). Casein is not coagulated by rennin 
when the solution is alkaline. When a sufficient amount 
of an alkali is given, the milk mixture remains neutral 
or alkaline in the stomach, even after the stomach has 
secreted acid, and large protein curds do not form then. 



1 Brenncman, J. : Boiled versus Raw Milk, J. A. M. A., lx, 575. 
1913. 



MILK DILUTIONS WITH CARBOHYDRATES. 145 

Lime-water is commonly used in amounts equaling 5 per 
cent, of the milk in the mixture (1 ounce to 20 ounces 
of milk). 

Not infrequently we have found the adding of citrate 
of soda or lime-water to boiled milk of advantage in the 
difficult feeding cases, and in the presence of vomiting. 

Mixed Diet for Young Infants. 

As early as the second or third month, 1 or 2 teaspoon- 
fuls of orange juice may be given daily. This in part 
at least counteracts the effect of boiling. Start with one- 
half teaspoonful diluted with water, twice daily, and 
increase gradually until the juice of a whole orange is 
given. 

Fifth month, a little well cooked cereal may be added 
to one of the meals (begin with 1 teaspoonful), adding 
part of the bottle of milk to it, the meal being finished 
by the remainder of the bottle, or it may be given in 
the bottle. Increase until 1 to 4 tablespoonfuls are 
added, once or twice daily. 

At sixth month, infants readily take a broth and vege- 
table meal as a substitute for one of the milk feedings, in 
the form of a vegetable and meat soup. Begin with 1 
ounce, and follow by a second bottle containing the milk 
mixture with 1 ounce less than full feeding. Gradually 
replace an entire, milk feeding. 

Ninth month, a vegetable soup or a clear broth 
(chicken, lamb, or veal), and toast or zwieback crumbs, 
with an additional portion of stewed fruits (apples, 
prunes) or a strained vegetable (spinach, carrots, pota- 
toes, asparagus tips, peas, celery, beets, or turnips). The 
broth is usually given in the same quantity as the bottle, 
if given alone, or somewhat less if either the tablespoon 
of vegetable or fruit is given in addition. 

Spinach, carrots or other vegetables may appear in the 
stool apparently unchanged, unless they are finely pureed. 
This may be disregarded If there are no signs of intes- 

10 



146 INFANT FEEDING. 

tinal irritation as the salts and vitamines are usually 
extracted, the colored cellular part remaining. It is to 
be remembered that the tubers, such as potato, are in 
reality largely starch and although valuable for their 
mineral content, they do not replace root or leaf vege- 
tables in the diet. 

Caloric Values of Foods. 

Amount Cal. 

Apple sauce 1 ounce 30 

Bacon (slice) % ounce 30 

Bread average slice, 33 Gm 80 

Butter 1 pat (% ounce) 80 

Cereal (cooked) 1 heaping tablespoonful 

(1 ounce) 50 

Carrots (cooked) 1 ounce 13 

Crackers (soda or 

Graham) 1 ounce 100 

Cream (16 per cent.) 1 ounce 54 

Custard 1 ounce 60 

Egg 1 (1.5 ounces) 80 

Egg (white) : 1 30 

Egg (yolk) 1 50 

Gelatin 1 ounce 50 

Malt extract 1 ounce 89 

Meat 1 ounce 50 to 70 

Milk (whole) 1 pint 350 

Milk (whole) 1 ounce 21 

Potato (whole) 1 medium sized 90 

Potato (mashed) 1 heaping tablespoonful 70 

Rice (boiled) 1 tablespoonful 60 

Soup (vegetable) 1 ounce 15 

Soup (chicken) 1 ounce 8 

Toast average slice 80 

Vegetables (peas, beans, 

carrots) 1 heaping tablespoonful 30 

Vegetable (cooked spin- 
ach) 1 heaping tablespoonful 16 

These caloric values are approximate for the most part, 
but are sufficiently accurate for practical purposes. Thus 
the caloric value of a particular menu is easily figured. 



MILK DILUTIONS WITH CARBOHYDRATES. 147 

Feeding Example No. 1. Normal Infant, Age Three 
Months. The infant should weigh 11 pounds (average 
birth-weight 7 pounds, plus 4 pounds, representing a 
gain of 5 ounces weekly for thirteen weeks). 

Estimating 1% ounces of milk per pound body weight, 
give 16% ounces of milk. 

Adding three grams of cane sugar per pound or 1 
ounce for each ten pounds, is 1.1 ounces of sugar, or 2% 
level tablespoonfuls per 11 pounds 

The infant should be fed five or six times daily and 
should receive at each feeding 5 ounces of mixture (age 
in months, plus 2 ounces). To make the total daily 
quantity 25 or 30 ounces as desired it is necessary to add 
Sy 2 or 13% ounces of water to the quantity of milk as 
given above. 

For practical purposes the cow's milk may be consid- 
ered as averaging: 

Proteins 3.5 per cent. 

Fat 4.0 " " 

Carbohydrates 4.0 " " 

We will now calculate the amounts of the various ele- 
ments in the mixture and the grams of each and calories 
per pound body weight in the milk mixture as given 
above for a 3 months old infant, weighing 11 pounds. 

Carbo- 
Protein Fat hydrate Salts Cal. 

Milk, 16.5 ozs .= 495 mils . . 17.3 19.8 19.8 3.46 Gm. 346 

Water, 8.5 " =255 " " 

Sugar, 1.1 " = 33 Gm 33.0 .... " 132 

ture, 25 ozs. = 750 mils .. 17.3 19.8 52.8 3.46 Gm. 478 
For each pound body weight . 1.575 1.8 4.8 0.31 " 43 

We thus find that the infant fed on the prescribed 
diet receives 25 or 30 ounces of the mixture containing: 

Protein 1.575 Gm. per pound body weight 

Fat 1.8 

Sugar 4.8 " " " " " 



148 INFANT FEEDING. 

The mixture containing the following percentages if 
made up for 25 ounces, (It will be noted that the per- 
centages of the food elements per ounce of the mixture 
vary directly with the amount of water added and is 
therefore an unreliable basis for calculation.) and 43 
calories per pound of body weight, all of which may be 
considered as a safe minimum. 

Protein 2.3 per cent. 

Fat 2.64 " " 

Sugar 7.00 " 

A fruit juice should be included in the diet (page 145). 

It may be repeated that the needs of the Individual 
Infant are to be covered by the Diet, and food of Higher 
Caloric Value per pound body zveight is needed by some 
Infants. ( Pages 140, 141 and 150.) 

The mixture may readily be strengthened to meet indi- 
cations for more fat and protein by the addition of milk, 
and more carbohydrate by the addition of flour and sugar. 

Form for Directions for Preparation and Feeding. 

This feeding formula may be given to the mother in 
the following form with directions for its further pre- 
paration attached. 

Name Age 

Milk 16.5 ounces 

Water 8.5 ounces 

Cane sugar 2.25 level tablespoon fuls 

(Milk Sugar: 3% level tablespoonfuls.) 

Place the above mixture in a double boiler, and starting 
with the water and the milk mixture cold, allow it to 
remain on the stove until the water in the outer vessel 
boils for 8 minutes. A small double boiler is preferable 
so as to obtain a deep column of milk, thereby holding 
the milk at a simmer. 

Feed 5 ounces at each feeding, five feedings at 4 hour 
intervals: 6 a.m., 10 a.m., 2 p.m., 6 p.m., and 10 p.m. 



MILK DILUTIONS WITH CARBOHYDRATES. 149 

Not infrequently while the ingredients in the diet fully 
meet the infant's needs for growth and development, the 
amount of the individual feedings are insufficient to sat- 
isfy the appetite. The infant can usually be satisfied in 
such instances by adding more water or cereal water to 
the mixture, thereby increasing the quantity of the indi- 
vidual bottle without materially altering its quality. 

It should also be remembered that some infants may 
require more milk than 1% ounces per pound body 
weight, or again, occasionally an infant cannot take a 
formula as strong as that given above, because of an 
inability to handle one or more of the cow's milk ele- 
ments, more commonly fat, protein or the excess of salts. 
In all exceptional cases the individual infant must 
necessarily have its needs fulfilled, by an increase or 
decrease in the milk components. 

Feeding Example No. 2. Normal Infant, Age Eight 
Months. The infant should weigh 17.25 pounds (average 
birth-weight 7 pounds), which should be doubled in the 
first five months (14 pounds), plus a gain of 4 ounces 
a week for the remaining thirteen weeks (3.25 pounds). 

The following mixture will be prepared : 

1.5 ounces of milk per pound body weight, equals 26 
ounces. 

Water to make one quart, equals 6 ounces. 

Sugar 1.5 ounces. As stated on page 130 the amount 
of sugar to be added is usually limited to 1.5 ounces, 
further carbohydrate needs being furnished by the ad- 
dition of cereal waters or cereals. 

Starch 0.25 ounce or 8 grams (approximately % 
ounce or 0.5 grams per pound). 

This to be fed in four feedings of 8 ounces each, and 
the fifth may be replaced by a soup and vegetable meal. 
A small cereal feeding (2 to 4 tablespoon fills') can also be 
given with 1 or 2 of the bottles, pouring part of the 
bottle of milk over it, and finishing the meal on the 
remainder of the bottle. (Mixed Diet, page 145.) 



150 INFANT FEEDING. 

Carbo- 
Protein Fat hydrate Salts Cal. 

Milk, 26.0 ozs.= 780 mils .. 27.3 31.2 31.2 5.46 Gm. 546 

Water, 6.0 " " = 180 " " 

Sugar, 1.5 " = 45 Gm 45.0 .... " 180 

Starch, 0.25" = 8 " 8.0 .... " 25 

Vegetable 

soup, 8.0 '• =240 mils .. 2.0 4.5 8.0 2.4 " 144 
Cereal, one heaping tablespoon- 

ful, 1.0 '• = 30 Gm 15.0 .... " 50 

Total feeding 29.3 35.7 107.2 7.86 " 945 

For each pound body weight . 1.7 2.1 6.2 0.46 " 55 

Further needs of the individual case can be supplied 
by concentrating the milk until 1 quart whole milk is 
given, the carbohydrates in the mixture being gradually 
decreased and given in another form, as gruel, custard, 
etc. 

Feeding Example No. 3. Underweight Infant, Age 
3 months. Weighing 8 pounds. To start with, prepare 
the following mixture : 

Milk 12 ounces. (V/% ounces per pound present 
weight). 

Water 13 or 18 ounces. Sufficient to make 5 or 6 
feedings of 5 ounces each. 

Cane sugar 0.8 ounces (1% level tablespoonfuls) 
(/4o ounce or 3 grams for each pound). 

To meet the requirements of this infant for growth and 
development, the needs of a full weight infant of the 
same age must be approximated as rapidly as the in- 
fant's tolerance for food permits. These increases can 
usually be made rapidly, if the infant is well other than 
for its underfeeding. The first increases being made in 
the carbohydrates in the form of further addition of 
sugar and cereal waters, until 3 grams per pound of 
sugar and 0.5 to 1.0 gram per pound of cereal flour in 
the form of cereal water are added, calculated on the 
basis of average full weight, 11 pounds, for this age. 



MILK DILUTIONS WITH CARBOHYDRATES. 151 

The milk can be increased until 1% ounces per pound 
of full weight, or 16.5 ounces for the total mixture are 
given. 

If the infant is suffering from digestive disturbances, 
it may be necessary to start with 1 ounce of milk or 
even less per pound of its present weight, that is 8 ounces 
or less in the mixture, adding only 1 or 2 grams of 
sugar per pound. It must, however, be remembered that 
the infant will require 32 calories per pound body weight 
to sustain it. And if it is underfed for too long a 
period, it will result in inanition. 

Artificial Feeding During the First Weeks of Life. 
The rules as given for infant feeding are hardly appli- 
cable for feeding during the first one or two to three 
weeks of the infant's life. The infant's first feedings 
should consist of higher dilutions of either whole or skim 
milk, should be boiled, and sugar added in smaller per- 
centages than suggested for the older infants. Such mix- 
tures must of necessity show a lower caloric value than 
will meet the infant's needs for growth and development, 
but, as suggested, the mixture for the newborn should be 
composed of weak formulae, and increased according 
to the infant's tolerance. The following table of mixture 
will act as an outline for average cases : 

Diet for Newborn Infants During the First Four 
Weeks of Life. 

1st 48 3-4 5-6 7-8-9 10-11-12 13-14 3d 4th 

hours days days days days days week week 

Milk (whole), ozs 3 4 6 8 11 

Milk (skim), ozs 6 8 5 4 4 2 ... 

Sugar (cane), dr 112 2 2 3 4 6 

Water (boiled), ozs. .. 16 10 8 8 8 8 8 10 

Calories in mixture ..15 81 118 148 158 215 250 321 

Feedings : 

Amount in ozs 1 2 

Number daily 6 6 

Intervals in hours . . 4 4 



2.5 


2.5 


2.5 


3 


3 


3.5 


6 


6 


6 


6 


6 


6 


4 


4 


4 


4 


4 


4 



152 INFANT FEEDING. 

The mixtures previously mentioned should be boiled for 
three minutes over the direct flame or in a double boiler. 
If the latter is used, the water in the outer vessel should 
be boiling for eight minutes. Add boiled water to make 
up the original quantity. 

Method of Feeding a Baby from the Bottle. Babies 
should be fed while they are lying on their beds, the 
upper part of the body being somewhat elevated by means 
of a pillow of proper thickness. The baby should be 
turned slightly on the right side, as it has been found that 
the stomach empties itself sooner in that position. 

The bottle should always be held by the nurse or at- 
tendant, until it is empty. From fifteen to twenty minutes 
should be occupied with the meal. 

Do the above rules furnish mixtures of a quality and 
quantity proper to meet the infant's needs? If proper 
mixtures they should 

(1) Contain approximately 

Protein 1.5 to 2.0 Gm. for each pound of body weight 

Fat 1.5 " 2,0 " " " " " " 

Carbohydrates . . 4.0 " 6.0 " " " " " " " 

(2) Calories per pound body weight for normal 

infant: 

Under 2 months of age 30 to 45 calories 

Over 2 months of age 45 " 55 " 

(3) Percentages in the mixtures. 

It is well to know the percentages of the various ingre- 
dients in the diet, as they will assist in the proper inter- 
pretation as to the etiology of food disturbances. 

Fat. Infants, according to their age, under normal 
conditions, digest from 2 to 3.5 per cent, of fat. Some 
infants digest fat badly, consequently in some cases it is 
necessary to give skim milk. 

Proteins. In the average feeding mixture for in- 
fants under 10 months, 2 to 3 per cent, of proteins are 
well taken. 



MILK DILUTIONS WITH CARBOHYDRATES. 153 

Carbohydrates. They should, as a rule, not exceed 
6 to 7 per cent., the average amount in human milk, in- 
cluding the sugar contained in the milk before its modi- 
fication. 

Summary. 

I. Preparation of the mixture. 

1. Calculate the baby's normal weight. 

2. Calculate the amount of cow's milk to be used in the 
preparation of the mixture, taking 1.5 ounces of cow's 
milk per pound of normal body weight at that age, which 
is a safe minimum for a healthy infant. 

3. Calculate the total daily amount of the mixture by 
multiplying the amount of each feeding (age in months 
plus 1 or 2 ounces) by the number of feedings. 

4. Add water to make the mixture up to this total 
amount. 

5. Add 3 grams of sugar, and later 0.05 to 1.0 gram of 
starch for each pound of body weight. 

6. Make the curd more digestible by boiling or alkalin- 
izing the mixture or using cereal water as a diluent. 

II. Checks on the above mixture. 

1. Number of grams per pound body weight of each 
food ingredient in the mixture. 

2. Total caloric value of mixture and caloric value per 
pound body weight. 

III. Remember that — 

1. Orange juice or codliver oil additions to the diet 
should be started by the second or the third month. 

2. When more than 1 quart of milk mixture is needed 
to properly nourish the infant, most infants have reached 
the age when a mixed diet should be instituted. 

3. These amounts are relative, and must be increased 
or decreased according to the infant's progress and in- 
dividual needs, the above rules furnishing a safe minimum 
for a healthy infant. 



154 INFANT FEEDING. 

4. The above amounts are usually insufficient for the 
underfed infant after it has become accustomed to the 
diet. Frequently it is necessary to approximate the re- 
quirements of a normal baby of that age. 

5. Premature and underfed infants must at first be fed 
smaller amounts. 

6. The food formula of a baby clinically healthy and 
making a satisfactory gain in weight should not be 
changed without a zvell-defined indication. 

Explanatory Note. For practical purposes we have used 
pounds for weight, and ounces for measuring fluids, because of 
the common use in the home of avoirdupois scales, and bottle 
and measuring glass graduated in ounces. We have also calcu- 
lated 1 oz. = 30 Gm., and 2.2 lbs. = 1 Kg. 



CHAPTER V. 
CREAM AND SKIMMED MILK MIXTURES. 

By the use of 16 per cent, cream and skimmed milk as 
the basis for obtaining various milk modifications, a wide 
range of combinations of the various food elements can 
be obtained. 

For feeding purposes, gravity cream, of which about 6 
ounces or somewhat less may be obtained from a good 
quality of milk contains fat 16, protein 3.5 and carbohy- 
drate 4.5 per cent. The skimmed milk may be obtained 
by carefully pouring off or dipping the cream. If this is 
carefully performed, it should contain F 0, P 3.5 and C 
4.5. Skimmed milk obtained by this method is not en- 
tirely fat free. However, any cream remaining in the 
lower portion would be balanced by a lesser quantity of 
fat in the cream used and the end result in making these 
mixtures would be about the same. 

The average infant should receive fat 1.5 to 2 Gm., pro- 
tein 1.5 Gm. and, as a minimum of added carbohydrate 3 
Gm. (above that contained in the cream and skimmed 
milk) per pound body weight. These will be obtained by 
the use of cream (16 per cent.), skimmed milk and sugar, 
which contain the following : 

Cream (16 per cent, fat), in 1 ounce, 5 grams of fat. 
Skimmed milk (3.5 per cent, protein), in 1 ounce, 1 gram of 

protein. 
Sugar (100 per cent, carbohydrate), in 1 ounce, 30 grams of 

carbohydrate. 

The following amounts will be needed : 

For each gram of fat, add Vr, ounce, or 6 mils of cream. 
For each gram of protein, add 1 ounce, or 30 mils of skimmed 

milk. 
For each gram of carbohydrate, add %o ounce, or 1 gram 

sugar. 

(155) 



156 INFANT FEEDING. 

In the mixture the ingredents will be used in the follow- 
ing amounts per pound body weight; 

Cream, % to 4 Ao of an ounce (Fat, 1.5 to 2 grams). 
Skimmed milk, \ l / 2 ounce (Protein, 1.5 grams). 
Sugar, Vio of an ounce (Carbohydrates, 3 grams). 

In the mixture the ingredients will be used in the fol- 
lowing amounts per kilogram body weight: 

Cream, 27 mils (Fat, 4.4 grams). 

Skimmed milk, 100 mils (Protein, 3.3 grams). 

Sugar, 6.6 grams (Carbohydrates, 6.6 grams). 

In the underweight infants the amounts would be cal- 
culated on the basis of present weight, at the beginning, 
but these would be increased gradually to the amounts 
necessary for a normal weight infant of the same age. 

Example: Given a ten pound baby, and desiring to 
feed the required amounts of fat, protein and carbohy- 
drates, which may be taken as 20 grams of fat, 15 grams 
of protein, and 30 grams of carbohydrate for one day's 
food, these quantities would be supplied by: 

Cream 4 ounces. 

Skimmed milk 15 " 

Sugar 1 " 

Water 8 

The small excess of protein in the cream may be con- 
sidered as a negligible quantity. 

It is readily seen that by thinking of the food require- 
ments per pound or kilogram body weight of the infant 
that the danger of over or under feeding is minimized as 
compared with the method so commonly in use by which 
the food ingredients are calculated on the basis of the per- 
centage content in the mixture. 

There can be no doubt as to the accuracy of the modi- 
fications which can be obtained by this method of feeding, 
but as previously suggested, it has the disadvantage of re- 
quiring considerable calculation due to the use of cream 
and skim milk in the place of whole milk and in actual 
experience the disadvantages to healthy infants of the 



CREAM AND SKIM MILK. 157 

possible excess of protein in mixtures made with simple 
dilutions of whole milk have been exaggerated. Prac- 
tical experience presents convincing evidence that far 
more infants develop gastro-intestinal disturbances from 
feeding excessively rich cream mixtures. The greatest 
objection to high milk feeding is high protein constipated 
stools which can be overcome by adding more sugar. 



CHAPTER VI. 

FEEDING IN LATE INFANCY AND EARLY 
CHILDHOOD. 

Mixed Diet After the Fourth Month. (See page 
145.) 
Feeding During the Last Quarter of the First Year. 

The following diet list will serve as an example for feed- 
ing during this period : 

Nine to twelve months diet. 

6.00 a.m. Milk mixture, 8 ounces. Milk, 6 ounces; water, 
2 ounces; sugar, 2 level teaspoonfuls. 

8.30 a.m. Orange or prune juice, ^ to 1 tablespoonful (0.25 
to 0.5 oz.). If preferable, this may be given 
with the 10 a.m. or 2 p.m. meal. 
10.00 a.m. Milk mixture, 8 ounces. Cereal (farina, oatmeal, 
etc.), 2 to 4 tablespoonfuls. 

2.00 p.m. Vegetable soup or a clear broth (chicken, lamb 
or veal), with an additional portion of a 
strained vegetable (spinach, carrots, potatoes, 
etc.). Vegetables can be started by the ninth 
month. The broth is usually given in the same 
quantity as the bottle, if given alone, or some- 
what less if a vegetable is given in addition. 
When starting the soup feeding, first replace 
1 ounce of the 2 p.m. bottle by 1 ounce of soup 
in another bottle; then give 7 ounces of the 
milk mixture. Gradually increase soup and 
diminish milk until an entire bottle of milk is 
replaced by soup. Gradually cut water and 
sugar out of the milk mixture until full milk 
is given by the tenth or eleventh month. 

6.00 p.m. Milk mixture, 8 ounces, and bread, zwieback 
crumbs or cereal. 

10.00 p.m. Milk mixture, 8 ounces, if needed. 

A slice of crisp bacon may be given to advantage dur- 
ing the eleventh and the twelfth months, probably best 
with the mid-morning meal. 

Note: For preparation of diets see Appendix. 

(158) 



FEEDING IN INFANCY AND CHILDHOOD. 159 

Four feedings a day are usually sufficient during the 
early part of the second year. In such a diet the fruit 
juices which may be given once or twice a day should 
not be considered as meals, and may be given between 
the regular feedings. Whole milk is now fed, and should 
not exceed 1 quart daily. The sugar and water are de- 
creased gradually. 

Twelve to fourteen months diet. 

6.00 a.m. Milk, 8 ounces. 

8.30 a.m. Orange juice, prune juice, or apple sauce (1 oz.) 
If preferred, this may be given with the 10 a.m. 
or 2 p.m. meal. 
10.00 a.m. -Milk, 8 ounces, and cereal (farina, oatmeal, etc.) 
4 or 6 tablespoonfuls, slice of crisp bacon. 

2.00 p.m. Vegetable or cream soup and zwieback, toast, etc., 
or a clear broth (chicken, lamb or veal), with 
additional portion of 2 to 4 tablespoonfuls of 
strained vegetable (spinach, carrots, potatoes, 
etc.). The broth is usually given in the same 
quantity as the bottle, if given alone, but some- 
what less if a vegetable is given in addition. A 
little scraped beef or beef juice may occasion- 
ally be added to the vegetable. Most infants 
may be given small amounts of coddled egg. 
6.00 p.m. Milk, 8 ounces, and bread, zwieback or cereal, 

custard or pap. 
10.00 p.m. Milk, 8 ounces, if needed. 
No milk should be given with the noon meal. 
After the twelfth month cow's milk should be limited to from 
V/ 2 to 2 pints daily. 

Fourteen to eighteen months diet. 
6.00 a.m. Milk 8 to 10 ounces 
8.30 a.m. Fruit juice (orange juice, prune juice, or apple 

sauce) 1 to 2 ounces. 
10.00 a.m. Cereal, 4 to 6 tablespoonfuls, with 2 ounces of 

milk or cream, followed by 6 to 8 ounces of 

milk. Toast, zwieback, crackers, or wafers 

may be alternated with bacon. 



160 INFANT FEEDING. 

2.00 p.m. (1) Vegetable or cream soup and zwieback or 
toast, or (2) a clear broth (chicken, lamb or 
veal), with an additional portion of four table- 
spoonfuls of vegetable mixture (spinach, car- 
rots, potatoes, etc.). The broth is usually given 
in the same quantity as the bottle, if given 
alone, but somewhat less if the vegetable is 
given in addition. 

Part or whole of a coddled egg with toast, 
zwieback or cracker crumbs can now be added 
to the above soup and vegetable meal. 

The egg may be alternated with beef juice 
or scraped beef. 

6.00 p.m. Cereal, 4 tablespoonfuls, farina, cream of wheat, 
oatmeal, arrowroot, custard or pap, with 8 
ounces of milk. Part of the milk may be given 
over the cereal, or as bread and milk, or milk 
toast. Jelly or honey with bread. 

10.00 p.m. Milk, 8 to 10 ounces. (Can usually be left out 
by this time.) 

Eighteen months to three years. 

7.00 a.m. Stewed fruit or orange juice; cereal; crisp bacon, 
alternate with soft boiled or poached egg; 
Bread and butter or toast ; milk or weak cocoa. 

12 or 1p.m. (1) Broth: meat or vegetable soup thickened 
with cereal. (2) Meat : lamb chops, scraped 
beef, chicken or beef juice. (3) Vegetable: 
baked or mashed potatoes; strained spinach, 
carrots, turnips or celery. (4) Dessert: gela- 
tine, custard, cornstarch or rice-pudding, or 
other simple dessert. 

6.00 p.m. Cereal and bread or cracker with milk. Baked 
apple, apple sauce or other stewed fruit. 



Other Foods Permitted at Three Years. 

Meats. Broiled or boiled fish, roast or stewed poultry, 
raw or stewed oysters, broiled beefsteak, roast or broiled 
beef or mutton — all in moderate quantities. 

Eggs. Soft boiled, poached or scrambled, 1 or 2 daily. 



FEEDING IN INFANCY AND CHILDHOOD. 161 

Cereals and Breads. Oatmeal, hominy grits, wheaten 
grits, cornmeal, barley, rice, macaroni, etc. Light and not 
too fresh wheat and graham bread, toast, zwieback, plain 
unsweetened biscuit. 

Soups. Plain soup and broth of nearly every kind, 
preferably vegetable broth. 

Vegetables. White potatoes, boiled onions, spinach, 
carrots, peas, asparagus (except the hard part), stewed 
celery, young beets, arrowroot, tapioca, sago. 

Fruits. Nearly all, if stewed and sweetened. Of raw 
fruits, peaches are the best; pears, grapes freed from 
seeds, oranges. 

Desserts. Light puddings, as rice pudding without 
raisins, bread pudding, plain custard, pap, wine jelly, ice 
cream, junket. 

Foods to be Taken with Considerable Caution. 
Muffins, hot rolls, sweet potatoes, baked beans, turnips, 
parsnips, cabbage, egg plant, stewed tomatoes, fresh corn, 
cherries, plums, raw apples, huckleberries, gooseberries, 
currants, preserved fruits. 

Foods to be Avoided. Fried foods of any kind, 
griddle cakes, pork, sausage, highly seasoned food, pastry ; 
all heavy, doughy, or very sweet puddings ; unripe, sour, 
or wilted fruit; bananas, cucumbers, nuts, coffee, alco- 
holic beverages. 



11 



PART IV. 

Nutritional Disturbances in Artificially 
Fed Infants. 



CHAPTER I. 
MINOR DISTURBANCES. 

1. Vomiting. 

Vomiting is one of the most frequent symptoms in 
the nutritional disturbances of infancy and childhood, 
and will be reviewed from the standpoint of its asso- 
ciation with this class of diseases, without reference 
to its occurrence in other systemic diseases. 

Overfilling of the stomach is one of the most fre- 
quent causes of vomiting in infancy. The young infant 
vomits easily, and without effort. The weak sphincter 
at the cardia predisposes to regurgitation. Regurgi- 
tation of only a small portion of the meal is desig- 
nated as "spitting." This latter symptom has become 
less common since the introduction of the longer feed- 
ing intervals, which allows the stomach to empty itself 
thoroughly before the next feeding. Other than too 
frequent feedings, too large an individual meal, and 
food too rapidly taken, are the most common causes 
of vomiting. These conditions are easily remedied. 

Not infrequently overfilling of the stomach is due 
to swallowing of air during nursing. Some infants are 
especially prone to swallow large amounts at each 
feeding, and unless this is relieved, it will lead to 
vomiting. This condition is frequently seen in young 
infants who are left unattended to feed from a bottle. 
This results in their nursing air from the partially filled 
(162) 



MINOR DISTURBANCES. 163 

nipple as the bottle becomes empty. It should be an in- 
variable rule to support the bottle in a semi-upright posi- 
tion for all infants until they are of such age as to enable 
them to properly hold the bottle for themselves. This 
will also insure their getting their food while still warm. 

Placing an infant in an upright position, preferably 
with its chest against the mother's shoulder at the end 
of the nursing and avoiding at the same time com- 
pression of the abdomen, so that the air bubble may 
rise to the cardia and be expelled, offers the best solu- 
tion for temporary relief. Some infants develop an 
extreme habit of air swallowing, and in these it may 
become necessary to put the infant in the erect posi- 
tion two or three times during the course of a nursing. 

Excessive handling and abdominal bands that are 
too tight are frequently causes of vomiting. 

Improper Diet. Excessive feeding with fat, such as 
is frequently seen in formulae made from cream mixtures 
and top milk mixtures, are common causes of vomit- 
ing, and should lead to reduction of the fat contents in 
part by whole or skim milk. Excessive quantities of 
sugar in the diet may also cause vomiting. Vomiting 
due to the large tough protein curd of raw milk can be 
obviated by boiling or alkalinizing the milk. 

Nervous vomiting or habit-vomiting is an exceed- 
ingly intractable and common form seen in many in- 
fants. In such cases the slightest excitement may pro- 
duce vomiting; such as crying, sudden movement of 
the infant by the mother or nurse. 

Spasm of the cardia or pylorus are frequent causes 
of vomiting more especially in early infancy. Spasm 
of the cardia is rarely diagnosed except by the radio- 
graph. In our experience these cases are found more 
frequently than formerly supposed. These types of 
vomiting may appear immediately after birth, but usu- 
ally do not develop for some days or even weeks, and 
sometimes not until the infant is several months old. In 



164 INFANT FEEDING. 

the milder cases this may be the only symptom and the in- 
fants may obtain sufficient food, and thereby avoid any 
interference with proper nutrition. In both types the 
vomiting may be explosive. This is more common in the 
pyloric type or when the two are associated. The vomitus 
shows, as a rule, little or no evidence of disturbance of 
digestion. In extreme types nutrition will suffer and the 
hunger stool is present. The presence of increased and 
visible peristalsis in the pyloric type may lead to the diag- 
nosis of organic stenosis. They can only be differen- 
tiated by the aid of a fluoroscope and radiograms fol- 
lowing a bismuth meal, together with a careful study 
of the history of its development and the effect upon 
the infant's development. 

Congenital hypertrophic stenosis of the pylorus is a 
frequent form of obstruction. Most frequently it 
comes into evidence between the second and the fourth 
week after birth. There is nothing characteristic 
about the vomiting in the beginning. It soon becomes 
forcible and explosive. The gastric contents may be 
shot out of the mouth to a distance of several feet. 
The vomiting usually occurs soon after the taking of 
food, but may occur at any time, sometimes not until 
just before the next feeding. Two or even more feed- 
ings, are sometimes retained and expelled together. 
The vomiting may be accompanied by pain. Consti- 
pation quickly develops, because so little of the food 
passes through the pylorus into the intestine, that 
there is but little residue to be passed out of the bowels. 
The stools are small and composed mainly of mucus. 
Increased peristalsis with visible waves traveling from 
the left to the right and ending at the pylorus with 
increasing size until vomiting occurs, or to the point 
of exhaustion on the part of the stomach, is a constant 
finding. In a large percentage of the cases, a small 
tumor may be felt at the pylorus when the infant is 
quiet and the abdomen is not too much distended. 



MINOR DISTURBANCES. 165 

Loss of weight is a constant symptom. The skin be- 
comes dry, the face pinched and the baby soon shows 
all the evidences of starvation. 

Rumination consists in repeated regurgitations of 
small amounts of the food taken and occurs some time 
after ingestion. Some of this is promptly swallowed 
again, but a considerable amount may be lost from 
the mouth. It usually lacks the forcible character that 
pertains to true vomiting. In the mild type the rumi- 
nation occurs only at long intervals, perhaps once or 
twice a day, and then is not so marked as to be accom- 
panied by any definite loss of food. This condition 
usually responds readily to proper hygiene and feeding, 
and causes very little anxiety. In the severe types we 
find a nervous, emaciated, pale child, which cries 
rather easily and does not sleep well. The food which 
is given the child is well taken. Soon after the bottle 
is taken, the child begins to bring the food up. 

The food which is brought into the mouth is gargled 
for a short time and then swallowed. This may hap- 
pen again and again, the interval between the attacks 
becoming exceedingly short. Some of the infants 
stimulate the attacks mechanically by putting the 
hands into the mouth, others by rotating or protruding 
the lower jaw. Commonly the regurgitation is initiated 
by a rigid extension of the body, a throwing back of 
the head, arching of the chest and contraction of the 
abdomen. Usually following the regurgitation the in- 
fant makes chewing movements upon such food as is 
not expelled and it is again swallowed. I have recently 
had such a case under observation, which showed a 
(marked dilatation of the esophagus and cardio- and pylo- 
rospasm. 

Acute gastric indigestion may also be caused by the 
ingestion of foods to which the infant is not accus- 
tomed, or by the accidental swallowing of foreign 
bodies. 



166 INFANT FEEDING. 

Rarer types of obstruction of the gastro-intestinal 
tract are occasionally seen, such as congenital or in- 
flammatory obstruction due to fibrous bands. Of the 
former I have recently seen two cases in which the 
lower end of the esophagus was obstructed by a band 
of adhesions, which was relieved by operation. Con- 
genital atresia of the small intestine may be mistaken 
for pyloric spasm or stenosis. Intussusception, vol- 
vulus, appendicitis, diverticulitis and the different types 
of peritonitis are all accompanied by vomiting. In all 
cases of vomiting of sudden onset of unknown cause, 
examination should be made for incarcerated umbilical 
and inguinal hernias. 

Treatment. The treatment of vomiting varies with 
its cause. 

Spasm of the cardia or pylorus in the artificially fed 
is often cured by a change to human milk. When 
human milk is not available, feeding with a concen- 
trated diet as thick cereal paste. 1 will frequently relieve 
the condition. Small feedings at more frequent inter- 
vals are often better retained. Re-feeding after vomit- 
ing may be necessary to avoid starvation. Boiling and 
alkalinizing the milk mixture is to be recommended. 
In the absence of organic obstruction, medication with 
atropine sulphate, paregoric and calcium salts may re- 
lieve the tendency to spasm. In the severer cases 
daily or even more frequent lavage with a weak solu- 
tion of bicarbonate of soda is valuable. It has been our 
experience that in some of the cases feeding by gavage 
resulted in the disappearance of the tendency to spasm 
in both the cardia and pylorus type. In some of our 
cases rectal instillation of normal saline or Ringer's 
solution at regular intervals for the relief of the anhy- 
dremia has seemingly resulted in a lessening of the 
spasm probably through reflex action. 

Congenital Hypertrophic Stenosis. The first indication 
for treatment is feeding small quantities of human milk 



Thick cereal gruel — see Appendix. 



MINOR DISTURBANCES. 167 

at short intervals. The further dietetic and additional 
treatment is the same as that recommended for pylo- 
rospasm. Surgical treatment, when indicated, should 
not be too long delayed, because of the danger of too 
prolonged starvation. The Rammstedt or its modifica- 
tion is the operation of choice. 

Rumination. The feeding of concentrated diets as 
thick cereal paste which increase the difficulty of re- 
gurgitation may alone result in a cure. In other cases 
mechanical methods may be employed such as splint- 
ing and pinning the arms down so that they may not 
reach the throat. The use of a dove-tail bandage about 
the chin and fastening over the head, or a cap made 
with tapes which fasten under the chin, as suggested 
by Batchelor 1 or plugging of the nostrils, all have been 
used with success, but will be attended with a certain 
number of failures. Radiographic study should be 
made of the esophagus, cardia and pylorus in every 
case, and treatment directed toward the relief of any 
anatomical anomalies which may be present. In older 
infants the psychic condition must be considered and 
all irritation and excitement avoided. In the hospital 
such an infant should be placed in a room by itself or 
screened from its immediate surroundings. 

2. Colic and Flatulence. 

Infantile colic is due to distention and increased 
peristalsis either in the stomach or intestine, or both, 
resulting in spasmodic contractions. 

The colic period of infancy is chiefly the first three 
months. After this time the peculiar susceptibility 
gradually diminishes. The so-called "idiopathic" form 
of colic is more commonly intestinal but not infre- 
quently the stomach alone may be the seat of origin. 



' Batchelor, M. D. and R. P.: Am. J. Dis. of Children. Vol. 17, 
1919. 43. 



168 INFANT FEEDING. 

The constant solicitude of the nurses, because the 
baby has "gas on the stomach" is unwarranted. All 
bottle-fed babies have gas in the stomach. They 
swallow it with their meals in the form of air. If the 
baby is gently raised to a sitting posture the gas will 
usually "come up." This may be done in the middle 
of a feeding if the stomach seems unusually distended. 

Some infants, more especially those of the neuro- 
pathic type, seem predisposed to attacks almost from 
birth. They are the fretful, sleepless type of infants 
and seem at all times eager to take food. They usually 
insist upon sucking their hands or some other object 
and are air swallowers. More frequently colic is due 
to increased intestinal peristalsis, often secondary to 
over-distention. Many cases of colic appear to have a 
nervous origin brought about reflexly as, for example, 
through chilling of the surface of the body. 

Constipation is very frequently associated with colic 
and flatulence, disappearing with the institution of a 
proper diet. As well as being a cause, the coexistence 
of constipation in the presence of other etiological fac- 
tors, tends to aggravate the colic. Repeated purgation 
for an existing constipation is a frequent source of pain 
in the intestines. More commonly the habitual colic, as 
seen in the young infant, may be taken as an evidence 
of gastric or intestinal indigestion, and may be due to 
one of several causes : ( 1 ) Too much milk at proper 
intervals, (2) too frequent feedings, and (3) mixture 
too rich in fat, or (4) excessive in carbohydrates. Re- 
gurgitation and vomiting are commonly associated, and 
not infrequently diarrhea results. By a careful study 
of the diet and observation of the stools the offending 
factor can in most instances be eliminated. Excessive 
flatulence can frequently be eliminated by reduction or 
change in the kind of sugar and cereal gruels. A reduc- 
tion in all the elements of the food may be temporarily 
necessary in the presence of severe symptoms. 



MINOR DISTURBANCES. 169 

Colic is a very common symptom in the pre-menstrual 
period of the mother and usually is present until a free 
flow is established. The infant should be left at the 
breast. 

Acute attacks of enteritis, peritonitis, appendicitis, in- 
tussusception and volvulus must be excluded in sudden 
acute attacks. 

Treatment must be directed to the elimination of the 
cause. 

In the nervous type of infants, which are frequently 
termed "colic babies," this condition may persist for 
several months and the treatment must be directed to 
palliative measures. A cure will result only with im- 
proved development and when the digestive organs at- 
tain their normal functions. This class of infants are 
easily spoiled and should be placed under the supervision 
of a capable nurse, if the mother has not the proper 
temperament to combat the child's disposition. 

Not infrequently the crying due to underfeeding may 
be interpreted as colic. Reduction of the diet of these 
infants is a source of danger. If the stools are good, 
and there is no vomiting, and the baby is gaining in 
weight, one should be convinced that it is not the cry 
of habit before making changes in the diet. 

In breast-fed infants attention to the health of the 
mother or wet-nurse, avoidance of excitement, regular 
exercise and regulation of the bowels are necessary. In 
both breast-fed and artificially fed infants prevention of 
constipation and over-feeding of the infant, more par- 
ticularly with high fat and carbohydrate mixtures are to 
be avoided. 

If the infant is doing well, notwithstanding the colic, 
it should not be removed from the breast, nor should 
radical changes in the method of feeding be instituted 
without definite indications. 

In feeding with raw milk the stools should be ex- 
amined for protein curds. If they are present, the milk 



170 INFANT FEEDING. 

should be boiled or alkalinized. Not infrequently the 
condition will be relieved in the artificially fed by sub- 
stituting whole or skimmed buttermilk mixtures for 
sweet milk. 

The addition of powdered casein in amounts varying 
from 5 to 20 Gm. dissolved in the day's milk mixture 
will often relieve colic, in all probability due to lessening 
of intestinal peristalsis. A similar result may be attained 
by the administration of calcium lactate two or three 
times daily, in doses of 0.3 to 0.6 Gm. (5-10 Grs.). 

The addition of 3 to 5 mils of liquid culture of active 
lactic acid bacilli or a corresponding amount of an ac- 
tive culture in dry form is valuable in the treatment of 
many cases, both in the breast and artificially fed. It 
should be continued for some time. 

The administration of mild carminatives in the form 
of camomile or fennel tea, peppermint water or aromatic 
spirits of ammonia (0.06-0.20 mil) (1-3 minims), or 
compound spirits of ether (0.25-0.30, 4-5 minims), are 
often effective as palliative measures. With the abdom- 
inal distention the most efficient means of relieving the 
intestinal tract is by massage or enemata. For the latter 
normal saline, weak soap suds or glycerine in water may 
be used. A glycerine suppository will usually accom- 
plish the same result. 

In prolonged attacks dry or moist heat may be applied 
to the abdomen together with a hot- water bag at the 
feet. In the severe cases an opiate may be needed for 
temporary use. Camphorated tincture of opium, in doses 
varying from 0.06 to 0.65 c.c. ( 1-10 minims), is the safest 
form of administration. 



3. Constipation. 

By this term is indicated a condition in which the 
number of evacuations are less frequent, smaller in 
amount or firmer and drier than would be normal for 



MINOR DISTURBANCES. 171 

the given infant. Constipation must be regarded as a 
symptom. The term is a relative one and as usually ap- 
plied relates more to the character than to the frequency 
of the stool in the normal infant. In the presence of 
underfeeding or starvation the total amount must be 
given consideration in order to properly interpret its 
significance. Under normal conditions the breast-fed in- 
fant under six months of age will average two to four 
movements daily. While the artificially fed infant, ex- 
cept while on the carbohydrate rich diet, will usually 
average only one or two movements. 

In the Newborn. The complete absence of stools 
due to congenital malformations of the gastro-intestinal 
tract, such as atresia of the esophagus or intestine, or 
imperforate anus, should not be classed as cases of con- 
stipation, and the cause can usually be ascertained by 
careful study of the history, time of onset and character 
of the accompanying symptoms and a roentgenological 
examination. Somewhat later the question of insufficient 
food as a cause of minimal stools must be considered. 
This may be due to mechanical obstruction due to spasm 
of the cardia or pylorus or hypertrophic stenosis at these 
orifices. The food taken in these conditions may be suf- 
ficient, but it is later lost through vomiting. On the 
other hand, insufficient food in the breast-fed during the 
first days or insufficient intake or improper diet in the 
artificially fed, may result in the so-called starvation 
stools which are frequently termed constipation stools, 
but are not properly so classed. Frequently the consti- 
pation is due to sluggishness of the intestines because of 
improper stimulation or lack of response to the mechani- 
cal irritation of the food due to muscular weakness or 
dilatation of the intestinal tract. This is most frequently 
seen in the lower part of the large intestine. 

In Infancy. During this age a large number of fac- 
tors may cause constipation. Not infrequently several 
factors are involved in a given case. In a proper con- 



172 INFANT FEEDING. 

sick-ration of the subject it should be borne in mind that 
the cause of the constipation, once the food has entered 
the intestines may lie in any one of. the segments of the 
tract, and may be due to insufficient secretion or exces- 
sive absorption, an improper diet or an atony of the 
intestinal wall. 

Mechanical. Among the more common types several 
have already been mentioned. The most frequent cause 
in this group is the large size of the colon, more espe- 
cially the sigmoid flexure and the rectum. This condi- 
tion may be due to or result in an atony of the intestinal 
and abdominal walls, or may produce kinks which result 
in temporary obstruction of the lumen. Obstruction may 
also be due to conditions outside of the intestine, such 
as fibrous bands or adhesions, which latter may be of 
pre- or post-natal origin. 

Reflex or Spasmodic. Reflex or voluntary retention 
of the stools may be due to painful anal conditions, such 
as fissures, ulcers or spasm of sphincter. The latter 
condition is frequently due to the accumulation of large, 
hard, dry fecal masses in the lower rectum, the more 
common causes of which will be described under Die- 
tetic Errors. 

Atony of the Intestinal Wall. This is one of the 
most important causes of chronic constipation and while 
not infrequently due to congenital causes, more com- 
monly it develops after birth. Hyposecretion of the thy- 
roid gland, represented in its extreme form in cretinism, 
is always associated with constipation due to atony of 
the entire intestinal tract. A similar condition is also 
seen in athrepsia, rickets and secondary anemia. All of 
these are usually associated with a weakness of the ab- 
dominal wall, which is an important predisposing cause. 
Affections of the central, peripheral and sympathetic 
nervous systems are infrequent, but important causes. 
Among these are chronic hydrocephalus, intracranial 
hemorrhage, inflammatory conditions of the brain and 



MINOR DISTURBANCES. 173 

spinal cord. Acute and chronic febrile diseases not in- 
volving the gastro-intestinal tract are usually accom- 
panied by constipation. Improper training and lack of 
exercise result in increasing weakness of the intestinal 
and abdominal walls. The same result may follow the 
excessive use of cathartics and sedative drugs. 

Dietetic Errors. Insufficient intake of food and 
water or an improper balance of the diet are the most 
frequent causes of constipation. Associated with these 
and to a large extent dependent upon them is a hypo- 
secretion of the intestines, liver and pancreas. On the 
other hand, as will be described later, an excessive in- 
testinal secretion may result from improper feeding and 
may in turn result in constipation, due to the formation 
of so-called soap stools. Food, especially its carbo- 
hydrate contents, is the normal stimulant of the intestine. 

In the breast-fed infant receiving a sufficient quantity 
of milk we rarely see true constipation because of its 
relatively high sugar content. The condition described 
as constipation in the breast-fed infant is usually due to 
disproportion between the peristalsis in the lower bowel 
and over-action on the part of the anal sphincter. In 
the underfed breast-fed infant, however, true constipa- 
tion may develop, due to insufficient stimulation of the 
intestines. In the latter class of cases, however, not 
infrequently numerous stools are passed which consist 
mainly of dark colored mucus. This represents the nor- 
mal secretion of the colon mixed with the color of bili- 
ary pigments and a minimum of food residue. Similar 
stools may be passed by the underfed infant on an arti- 
ficial diet ; this may be due to too small quantities of 
food or too weak food mixtures, leading to insufficient 
residue to form a normal amount of feces. Infants fed 
on cow's milk mixtures, especially when insufficient 
sugar is added, will in time pass soap stools which are 
dry and putty-like and alkaline in reaction, with a result- 
ing constipation. This error in feeding will be given 



174 INFANT FEEDING. 

further consideration under the title of Overfeeding 
with cow's milk with insufficient carbohydrates. In- 
fants fed on diet low in fat, although it may contain 
a sufficient amount of carbohydrates and protein, fre- 
quently have an accompanying constipation due to the 
fact that the carbohydrates and protein are almost com- 
pletely absorbed and little residue remains. A consider- 
able portion of the fat ingested in high-fat diets is ex- 
creted in the feces as fatty acids, neutral fat and fat 
soaps. Excessive quantities of slowly fermentable carbo- 
hydrates, such as starch, will lead to constipation, unless 
accompanied by sufficient sugar which by its more rapid 
fermentation causes active peristalsis. From the fore- 
going a conclusion may be drawn that the proper bal- 
ancing of a diet, as discussed under infant feeding, is 
of importance in the prevention of constipation. 

The boiling of milk may be the cause of constipation, 
in large part due to the fact that the breaking of the 
curd leads to more rapid digestion and secondly due to 
the fact that these smaller curds result in less irritation 
of the intestinal wall. Both of these factors result in 
more complete absorption of the intestinal content. It 
should be remembered that the average infant which is 
thriving on its diet and making normal progress, even 
though it is passing "soap stools," is not in need of 
radical dietetic changes. More commonly a simple re- 
adjustment of the food ingredients will result in a change 
in the character of the feces. Only a careful study of 
the physical development of the infant, which should 
include examination of the blood, urine and osseous sys- 
tem, should lead one to the conclusion that the constipa- 
tion is of pathological significance, due to an improperly 
constituted diet. 

Diagnosis. Every effort should be made to discover 
the cause and the principal seat of the constipation. To 
arrive at the cause, the infant's age must be given con- 
sideration and a careful study must be made of its diet, 



MINOR DISTURBANCES. 175 

habits and constitution. Most of the non-inflammatory 
obstructions are seen in the first days or 1 months of life, 
and are equally common in the breast-fed. Whether due 
to obstruction or diet, it is important to determine 
whether the seat of the trouble is in the small intestine, 
colon or rectum. In both the breast- and bottle-fed in- 
fants, if local means, such as suppository or enema, will 
result in rapid passing of a normal stool, the fault will 
usually be found in the rectum, which is in need of in- 
creased stimulus to assist .it in emptying. This is espe- 
cially common in breast-fed infants, as well as artificially 
fed, who are too young to make use voluntarily of the 
abdominal wall. These cases are usually unaccompanied 
by other symptoms, unless the stool be hard and dry, 
which may result in injury to the anus. In the cases in 
which an improper diet is the underlying factor, the 
stools are usually pathological and are associated with 
evidences of discomfort, flatulence, irritability and in- 
sufficient gain in weight. Cerebral disease, as well as 
constitutional inferiority, as seen in cretinism, rickets, 
athrepsia and other systemic conditions must be properly 
interpreted. 

Treatment. In breast-fed babies, and not infre- 
quently in infants fed on boiled milk, we frequently find 
a sluggish rectum, which is evacuated to better advan- 
tage by the use of simple mechanical means than by the 
use of physics. A lubricated catheter, a simple sup- 
pository made from glycerine or soap, or one or two 
ounces of a saline enema or sweet oil injection, can be 
recommended. If properly used, they are not harmful, 
nor do they create bad habits which are often ascribed 
to them. A regular hour for their use, with proper 
training, creates regular habits, and in most instances 
the condition improves to such an extent that they can 
be discontinued. Most infants can be trained to regular 
evacuations by the fourth or fifth month. The infant 
should be well supported on the mother's lap, over a 



176 INFANT FEEDING. 

chamber, which she may hold between her knees. This 
is done to best advantage after a feeding or just before 
the morning bath, and a suppository may be used until 
the infant realizes that the operation is undertaken for 
a purpose. Abdominal massage, instituted at a regular 
time, is of great assistance in promoting the emptying 
of the lower bowel. In older infants this may be com- 
bined with muscle exercises. 

The treatment of the anomalies of the gastro-intestinal 
tract causing constipation is usually surgical. 

Drugs, except for temporary use, should be given the 
last consideration in the treatment of constipation. The 
stronger cathartics, such as salines, castor oil or calomel, 
are to be avoided. When the dietetic and local measures 
fail, the addition of one or two teaspoonfuls of milk of 
magnesia (Magma magnesia? N. F.) to the day's feed- 
ing, or the administration of mineral oil in doses suitable 
to the infant's age may become necessary. 

Constitutional conditions must be corrected by proper 
treatment. 

Dietetic Treatment. In the breast-fed infant usually 
no change in the diet is indicated, unless it is insufficient 
in amount. In the artificially fed infant a change in 
the character of the food may be all that is necessary 
to overcome even protracted constipation. 

In the presence of soap stools in infants who are 
thriving, usually a reduction in the amount of whole 
milk or substitution in part with skimmed milk tempo- 
rarily and an increase in the amount of sugar will often 
change the character of the stool sufficiently to relieve 
the accompanying constipation. It should, however, be 
remembered that the so-called soap stools are most fre- 
quently seen in the artificially fed infant on high milk 
mixtures, and that it is a common finding in infants who 
are making excellent progress. 

Under such circumstances radical dietetic changes are 
not indicated. And it should be remembered that in an 



MINOR DISTURBANCES. 177 

attempt to overcome this type of constipation great in- 
jury may be done, if the fat and protein content in the 
diet are reduced excessively. The use of local means 
to assist in emptying of the rectum is therefore to be 
advised rather than the institution of extreme changes 
in the diet. 

When the feeding of high milk mixtures with an in- 
sufficiency of carbohydrates has resulted in systemic 
changes associated with loss of turgor, stationary weight 
and metabolic disturbances, a radical change in the diet 
is indicated, and this will be treated more in detail under 
the heading, Overfeeding with cow's milk mixtures 
with insufficient carbohydrates. 

In the presence of constipation, where the maltose- 
dextrin compounds have been used, a change to milk- 
sugar or cane-sugar, or one of the maltose-dextrin com- 
pounds containing a high percentage of maltose and 
potassium carbonate is often indicated. Occasionally 
the addition of cereal water to the diet is of benefit. 
Those made from whole cereal are more valuable than 
when prepared from the dextrinized flour. The addi- 
tion of from one to three tablespoonfuls of the dry or 
liquid malt-soup extracts added to the day's feeding, is 
frequently all that is necessary to relieve constipation. 
In infants where constipation is distressing and other 
dietetic changes fail, a week or two on Keller's malt 
soup will relieve the condition. (See Appendix.) 

When the infant is old enough constipation is best 
relieved by the addition of vegetable soup or vegetable 
and fruit purees. 

4. Abnormal Stools. 

Number. Breast-fed infants usually have one to four 
stools a day. Bottle-fed infants have one or two, and 
infants fed on high milk and low carbohydrate diet usu- 
ally require some local measure to induce even one. The 
fewer the stools passed the greater is the likelihood that 
12 



178 INFANT FEEDING. 

they will be constipated. Increased peristalsis and secre- 
tion tend to increase the number of stools. Strong acid 
or alkaline bases tend to irritate the mucous membrane, 
more especially of the large intestine, with resulting 
loose stools. These types of stools also have a tendency 
to irritate the buttocks if not removed shortly after be- 
ing passed. The hard casein curds, seen when an ex- 
cess of raw milk is fed, also tend to increase peristalsis. 
Frequent stools are usually associated with an increase 
in mucus, the same factors causing both conditions. 

Reaction. Tests. Blue and red litmus paper may be 
used to test the reaction. It may be necessary to moisten 
the stool before making the test by adding a few 
drops of water. The central portion of the stool should 
be used for making the test in order to avoid its being 
affected by urine. Breast-milk stools are almost always 
acid. Those of the artificially fed are acid if the fat 
and carbohydrate in the diet outweigh the protein. If 
the reverse is true they may be alkaline. This is espe- 
cially common with the skim lactic acid or sweet milk 
mixtures with low sugar or fat. In the majority of 
instances stools when well digested will be found to give 
a neutral reaction and will not affect the litmus paper. 

Color. Breast-milk stools are usually yellow to 
orange. 

Green Stools. More especially when frequent in num- 
ber they may pass with a greenish tinge, due to the fact 
the biliverdin is passed before it can be reduced, or they 
may be passed as yellow stools and turn green after 
passage. Green stools in an infant making good progress 
have no great significance. In the artificially fed, more 
especially, the soap stools tend to turn green upon stand- 
ing, due to the oxidation of the bile salts from bilirubin 
to biliverdin. This is especially true in the presence of 
moisture, as from being saturated with urine. 

High protein stools have a tendency to vary from 
gray to olive green and the green color is compatible 



MINOR DISTURBANCES. 179 

with normal health and unless the infant is not thriving 
should not lead to radical change in the diet. 

In the artificially fed infant there is a tendency for 
the stools to assume a gray, putty-like appearance after 
the first few weeks on an artificial diet consisting largely 
of cow's milk and sucrose or lactose. Malt sugars, when 
fed in moderately large quantities, tend to give the stools 
a brownish tinge. 

Gray stools are those in which the bile salts have been 
reduced in a large part to urobilin, the biliverdin being 
practically absent. This is characteristic of the so-called 
soap stools seen in high milk and low carbohydrate feed- 
ing. 

Brown stools may vary from a light to a deep brown 
in color. In most instances this is due to feeding with 
the various maltose-dextrin compounds. Deep brown 
color is especially characteristic of feeding with Keller's 
malt soup and when extract of malt is added to the milk 
mixtures to overcome constipation. The color will vary 
directly with the amount of malt added. The cereal 
waters, when added in considerable amount or strength, 
tend to tinge the stools brown. In older infants meat, 
meat juices, some of the vegetables, and iron given in 
the form of medication will color the stools. 

Pink Stools. Urates from the urine may cause a pink 
color around the edge of the feces. This may also oc- 
cur through oxidation of the bile salts or through the 
action of the alkali in the napkin on urine or stool. The 
latter conditions are, however, exceptional. 

Dark Stools. Meconium may vary from green to dark 
brown or even black. Starvation stools, consisting largely 
of mucus and containing little fat residue, are usually 
dark brown in color, due to the pure bile salts contained. 
The drugs which are most frequently administered and 
cause dark stools are iron, bismuth, argyrol, and char- 
coal. 



180 INFANT FEEDING. 

Bloody Stools. The influence of blood on the color 
of the stool depends upon the amount and time of con- 
tact with the intestinal contents. Only blood which is 
passed shortly after hemorrhage retains its bright red 
color. Old blood gives the stool a tarry appearance. In 
the new-born it is often difficult to differentiate this 
from normal meconium. This should be borne in mind 
in considering the possibility of the presence of hemor- 
rhagic disease in the new-born. In infectious diarrhea 
blood is frequently seen in stools, the result of hemor-r 
rhage from ulceration in the wall of the colon and ap- 
pears as specks or masses and is more often of bright 
red color. These cases usually show an excess of mucus 
as well. Smaller blood masses may occur in the pres- 
ence of polyps and fissures in the rectum and anus. In 
intussusception blood and mucus form the basis of the 
stool and after the first movement there is little fecal 
matter. 

Odor. Breast-milk stools usually smell sour. Diets 
containing large amounts of carbohydrates in proportion 
to the milk contained have a more or less marked ten- 
dency to a sour odor. This is especially true in feeding 
with Keller's malt soup. The soap stool and the stools 
of infants fed upon high proteins have a very foul odor. 
The starvation stool has a peculiar musty odor, due to 
an excess of mucus. This stool is characteristically seen 
in under-fed infants and in those on starvation diet. 
Butyric and lactic acids, when present in considerable 
amounts, can be detected by their odor. The odor of 
decomposing urine, more particularly when there is a 
marked ammoniacal odor, will cover up the odor of the 
feces. Therefore, to determine the fecal odor the stool 
should be examined shortly after it is passed. 

Characteristic Types of Stools. Starvation stools are 
usually greenish brown or brown in color, contain little 
fecal matter, are composed mainly of mucus and have 
a tendency to have a moldy or musty odor. They are 



MINOR DISTURBANCES. 181 

most commonly seen in the severe types of vomiting 
and anorexia or when there is inability to swallow the 
food, also at the end of the starvation period in the 
treatment of diarrheal disturbances. Care should be 
taken so that the starvation stools will be differentiated 
from the meconium in the new-born, otherwise nursing 
on dry breasts may be overlooked. They must also be 
differentiated from stools containing decomposed blood. 

Curdy Stools. Curds are seen as undigested masses, 
and may be formed from fat or protein, or a combina- 
tion of the two. 

Fat curds are far more common than protein curds, 
and are usually seen as small, soft, whitish or yellow 
masses, either sprinkled throughout the stools or not 
infrequently making up a large part of the stool. They 
are usually intermixed with mucus, which is present in 
excess; in fact, most of the curds are completely sur- 
rounded by mucus which interferes with its digestion. 
The chemical composition can easily be demonstrated 
by the usual tests for fat. Breast-fed infants very com- 
monly show curds of this type, and usually they have 
very little pathological significance in these infants. The 
mucus is probably secreted in large amounts because of 
the irritation caused by the presence of fatty acids. Mis- 
takes are often made in the interpretation of this last 
group of stools. Because they are full of fat curds it 
is supposed there must be a fat indigestion. The curds 
are the result of indigestion or constipation, rather than 
the cause. 

Casein curds are far less frequent, and present quite 
a different appearance. They are seen only in the pres- 
ence of feeding with razu milk. 1 They appear as smooth, 
hard masses, of a yellowish-brown color, with white cen- 
ter when broken, and are usually larger than the fat 
curds. They are also fewer in number, and may be 



Brenneman, J. : Archives of Pediatrics, xxxiv, 81, 1917. 



182 INFANT FEEDING. 

found mixed in feces which otherwise appears normal. 
The addition of ether, which causes the fat curds to go 
into solution, results in hardening and toughening of the 
protein curds. This is an easy method of differentiation. 
Such stools have usually an offensive odor. 

The fat curds, if numerous, call for a considerable 
reduction in the fat percentage. The protein curds, if 
numerous and persistent, should lead one to reduce the 
milk, at least temporarily, or to boiling or citrating the 
milk, which causes their disappearance. In a dyspeptic 
infant on a high sugar diet with hard curds in the stools, 
reducing the sugar from the raw milk mixture, thereby 
lessening the frequency of stools and slowing peristalsis, 
may cause the hard curds to disappear — that is, the sugar 
diarrhea which prevented digestion of the casein has 
been remedied. 

Neutral fat is rarely present in stools, and when found 
is often indicative of fat intolerance. In most instances 
when it is found, it is proved later to be not from the 
milk but from castor oil, olive oil, or some ointment 
used on the baby. Fatty acids are not uncommonly 
found. Breast milk stools contain them frequently and 
are not considered pathologic. When found in cow's 
milk stools, it signifies impaired fat absorption. Stools 
containing free fatty acid globules almost always contain 
also many fat curds and a great deal of mucus. In 
considering fatty acids it must be remembered that 
formic, acetic, butyric, lactic, succinic acid, etc., are fatty- 
acids or derivatives of them, as well as stearic and oleic 
and palmitic acid. Formic acid, acetic acid, etc., are 
lower in the series, more irritating to the mucous mem- 
brane, and soluble in the watery content of the stool, 
not appearing on microscopic examination. Stearic, 
oleic and palmitic acids are very complex and high in 
the series, are insoluble in water, presenting themselves 
as oily, colorless globules, and are easily distinguishable 
as red or orange globules when stained with Sudan III. 



MINOR DISTURBANCES. . 183 

In examining a stool for fatty acids, we look only for 
globules. Finding none, we presume that that particular 
phase of fat indigestion is not present. But the stool 
may be very acid from the presence of fatty acids lower 
in the series that do not form globules but are in solu- 
tion, and clinically it makes little difference whether the 
higher or lower fatty acids are present. 

Soap Stools. These are light in color, large and dry, 
and do not adhere to the napkin. They are seen in 
feedings in which cream or whole cow's milk is in the 
excess as related to the carbohydrate content. 

Grover 1 says that the normal soap stool contains soap 
and protein matter, the proportion varying with the rela- 
tive amount of fat and protein in the food. If the fat 
in the formula is high and the protein low, we shall get 
a typical soap stool, provided there is no indigestion. 
Such a soap stool is formed and of very light color. 
They are usually dry and constipated. Soap stools 
rarely number more than two a day. They are alkaline 
in reaction, sometimes almost neutral. When spread out 
they appear smooth and dull. On microscopic exami- 
nation, no neutral fat or fatty acids are found ; but on 
being heated with acetic acid, almost every particle of 
solid matter is found to be changed to globules of fatty 
acids, formed from the soaps. As the protein in the 
food is increased and the fat decreased, there will be 
found more and more solid matter on the slide, that will 
not break down with heat and acetic acid. This raises 
the question of the value of the microscopic examination 
of the stool for soaps. It has usually been considered 
that when the microscopic field was "loaded" with glob- 
ules, i.e., virtually all the solid matter changed to glob- 
ules of fatty acids, the baby was not taking care of the 
fat very well, or might be on the edge of an acute ex- 
acerbation of a chronic fat intolerance. If the baby 



Grover, Joseph I.: Jour. A. M. A., 1921, 76, 365. 



184 INFANT FEEDING. 

were taking a formula composed of 3 per cent, of fat 
and 1 per cent, of protein, we should expect to find lit- 
tle else besides soaps in the stool. If the fat in the food 
should be kept at 3 per cent, and the protein raised to 
2.5 per cent., we should get a different picture micro- 
scopically. We should find that only one-third or one- 
half of the solid matter was changed to globules, the 
remaining solid matter being derived from the protein 
in the food. Just as much soap will be passed in the 
clay, but on microscopic examination it will seem much 
less because it is scattered and separated by the increased 
amount of protein matter. Microscopic examination of 
a stool for soaps, without considering the formula, is 
just as misleading as trying to estimate the red count in 
a fresh blood smear by comparison with the white cells 
without first having made a white count. 

Boiled High Casein, Lozc Fat Mixtures. These stools 
are most typically produced when any fat- free milk, 
which has been boiled from three to five minutes, is 
fed in amounts over two ounces per pound of body 
weight and in the presence of minimum or moderate 
amounts of sugar. Their consistency may be soft but 
more frequently they are quite solid and have a tendency 
to dry out rapidly. They usually have a greenish tinge, 
shading to light brown. When fat-free lactic acid milk 
is used in place of sweet skim milk they are somewhat 
more of a brownish shade. Grover has called attention 
to the very characteristic shiny surface produced when 
a tongue depressor or spatula is passed through it. This 
sheen must be differentiated from the glistening appear- 
ance of mucus and also from the natural moisture of all 
normally passed stools, clue to their watery content. The 
high protein stool is dull on the outside, where it is dry 
from contact with the napkin and in this respect greatly 
resembles the soap stools. 

As the fat in the diet is increased the greenish color 
and transparency soon disappear and with further in- 



MINOR DISTURBANCES. 185 

crease in the fat the smoothness and gloss are lost, and 
when the fat outweighs the protein the dull soap stool 
appears. The high casein stool described should be con- 
sidered a normal one when feeding large quantities of 
boiled skim milk. As stated, the characteristic appear- 
ance changes directly with the amount of carbohydrate 
and fat added. 

In the presence of an excess of fat and protein in the 
stool, upon heating with acetic acid and then staining 
with Sudan III, the soaps are changed into fatty acid 
globules, while the protein is seen as solid matter that 
is not affected by the heat and acid. 

Carbohydrate Stools. Starches are readily stained 
with dilute tincture of iodine or Lugol's solution. The 
particles of undigested starch stain blue or black. Stools 
containing much fermented starch are loose, acid, light 
brown, and excoriating, and contain much mucus. In 
fact, these stools are often mistaken for mucus. This 
type of stool is most likely to be found in babies having 
indigestion from certain of the starchy proprietary foods. 
Small, brownish specks are often found in normal stools, 
representing the indigestible cellulose envelops of cereal 
foods. 

Indigestion of sugar presents no typical stool. Stools 
resulting from sugar fermentation are frequent, very 
acid and excoriating, and often watery. The solid parts 
are usually full of small air bubbles, formed by the 
chemical decomposition. These may be demonstrated by 
pressing out some of the stool between a slide and cover 
glass and examining with the low power. The stools 
are usually green because of the action of the acids on 
the bile pigments. Stools from sucrose or lactose fer- 
mentation are green, while those from maltose-dextrin 
preparations are brown. 



186 INFANT FEEDING. 

5. Milk Idiosyncrasy. 

A few infants show a true idiosyncrasy to cow's milk, 
which is overcome only with great difficulty, even when 
the milk is carefully modified. The true cause of this 
condition is still in dispute. However, it may be said 
that some of these cases are undoubtedly due to anaphy- 
laxis. On the other hand, some of them are undoubtedly 
not explained on this basis. Infants suffering from such 
idiosyncrasy will usually refuse the milk, and when it is 
forced upon them it results in vomiting, diarrhea, and 
frequently an urticario-erythematous rash. Cow's milk 
feeding in these cases is often associated with a low- 
grade fever. The symptoms speedily subside upon the 
administration of castor oil and the withdrawal of milk. 
This class of cases offers great difficulty in feeding during 
the first year of life, as carbohydrates must necessarily 
form a considerable portion of their diet. Broths, cooked 
cereals, and vegetable purees should be gradually added 
to the diet as soon as they can be digested. 

Replacing the cow's milk in the diet by goat's milk 
will, in many cases, relieve all symptoms. 



CHAPTER II. 

GENERAL CONSIDERATION OF NUTRITIONAL 
DISTURBANCES. 

Evolution of the Conception of Nutritional 
Disturbances. 

Our ideas on this subject have undergone considerable 
change during the past few years. Older authors viewed 
the nutritional disturbances as conditions limited to the 
stomach and bowel, and likened them to similar condi- 
tions in the adult, with the exception that more serious 
results were to be expected in the infant because of the 
slight physiological resistance, the infant's body being 
more favorable to a severer course. 

For many years the classification of Widerhofer, of the 
Vienna school, first published in 1880, and based on an 
anatomico-pathological basis was the one in general use. 
These conditions he grouped as follows : 

1. Functional disturbances, as acute and chronic dys- 
pepsias. 

2. Enterocatarrhs, with more or less marked histo- 
logical changes and clinical findings. 

3. Follicular enteritis, with deep-seated inflammatory 
and ulcerative changes, especially in the large intestine. 

4. Cholera infantum (this latter, a severe type of en- 
terocatarrh, was classed as a distinct clinical entity). 

Clinical observation soon convinces one that the cases 
do not follow the distinct types in the above classification, 
mixed and progressive types being the rule. In many in- 
stances far-reaching after-effects remain, and, again, in 
others of the severest types few if any anatomical lesions 
are demonstrable at autopsy. Especially in young in- 
fants we find marked and often general disturbances fol- 
lowing in the wake of what seemingly were localized gas- 

(187) 



188 INFANT FEEDING. 

tro-intestinal lesions, with the result that the systemic and 
not the intestinal symptoms were of more serious import. 
Again, we know that many findings formerly attributed to 
invasion of bacteria or their toxins can now be at- 
tributed directly to improper metabolism of the food 
ingested. 

Food Injuries. The nomenclature covering this sub- 
ject has also changed, and we now adopt the term 
"Nutritional Disturbances" in place of "Gastro-intestinal 
Diseases," the former covering the functional and ana- 
tomical disturbances, as well as the bacterial and food 
traumas. It is, however, necessary in order to justify 
the newer nomenclature to look upon nutritional disturb- 
ances not as localized in the gastro-intestinal canal, but 
as general affections involving the whole organism in one 
of the most vital of its functions. The gastro-intestinal 
symptoms form only a part of the clinical picture ; there- 
fore, in its fullest conception the mental state, weight 
disturbances, changes in the temperature,, pulse, respira- 
tion, etc., may become as important in their interpreta- 
tion as the diarrhea. Two schools of pediatrics have 
given us the nucleus for our present views on nutritional 
disturbances and their classification — those of Czerny and 
Finkelstein. Czerny's work antedated that of Finkel- 
stein by several years, and he based his classification on 
what he considered injuries due to overfeeding with in- 
dividual food elements. These he called "food injuries," 
and described them as due to fat, starch, sugar, protein, 
and salts, individually or in combination, either when 
given in excess, or when given to an infant with lowered 
tolerance for these food elements. 

Finkelstein viewed the nutritional disorders from a 
broader standpoint. He considered them "as the gradual 
development of an increasing intolerance for food" — 
step by step, from the mildest disturbances, in which the 
only striking symptom is failure to gain in weight, 
through the severer diarrheas, up to the final stage of 



NUTRITIONAL DISTURBANCES 189 

intoxication, when the infant is in a state of "metabolic 
bankruptcy." In his classification we see one increasing 
process, the important factor of which is found in the 
fact that the infant can tolerate less and less food, until 
finally any food in any amount acts harmfully. The 
stages of the various disorders under the Finkelstein 
classification must therefore necessarily merge gradually 
into one another, and lack in defmiteness, and at times 
present a picture so complicated that an exact diagnosis 
as to the stage be temporarily impossible. 

The schools of Czerny and Finkelstein laid the prac- 
tical foundation for the combined etiologic and clinical 
classifications which form the working basis for our 
present grouping of nutritional disturbances. The no- 
menclature of Finkelstein applied to the groups in his 
clinical classification, namely Disturbed Metabolic Bal- 
ance, Dyspepsia, Decomposition and Intoxication, except 
for the latter, give the clinician very little insight into 
the underlying etiologic .causes. In the first two editions 
of this book, the Finkelstein terminology was used, but 
in this third edition the more descriptive terms. 

Overfeeding with Cow's Milk with Insufficient Carbo- 
hydrates replaces the Disturbed Metabolic Balance. 

Nutritional Disturbances Characterised by Diarrhea 
replaces Dyspepsia. 

Athrepsia and Marasmus replace Decomposition. 

Anhy.dremic Intoxication replaces Intoxication. 

Before entering upon a general discussion, it may be 
wise to review some of the theories promulgated for the 
advantages of human over cow's milk in infant feeding. 
Biedert believed that the decomposition products of pro- 
tein digestion were the important factors. This idea has 
not been substantiated clinically. Hamburger advanced 
the idea that the albumins foreign to the human body 
contained in cow's milk were important factors. This 
is true in a limited number of cases of milk idiosyncrasy. 
Czerny believed that the fat, and, again, the sugar, are 



190 INFANT FEEDING. 

the important factors. L. F. Meyer believed that the 
whey content, and more especially the high salt content 
of whey (0.75 per cent, as compared with 0.2 per cent, 
in human milk), predisposed to intestinal injury, follow- 
ing which trauma, fats and sugars play an important part. 
Marfan, Escherich, Pfaundler, and others believed that 
specific protective bodies of unknown nature were con- 
tained in raw human milk, which are of vast importance 
as immunizing bodies. 

Etiology. In the proper consideration of the nutri- 
tional disturbances we must consider the whole organism 
rather than an individual organ or system of organs, in 
formulating our diagnosis and outlining a course for 
treatment. In past years the tendency has been to con- 
sider the gastro-intestinal disturbances as conditions 
limited to these organs without due consideration of the 
systemic involvement, both preceding and following in 
the wake of traumata which primarily affected the di- 
gestive tract. It is also to be remembered that when we 
have an involvement of the gastro-intestinal tract, that 
only rarely is the underlying pathological condition 
limited to a single segment, but that much more fre- 
quently the entire tract, including as well the accessory 
digestive organs, are likely to be involved. 

In the study of a given case it is first necessary to 
decide, if possible, as to whether it is a mild or a seri- 
ous disturbance. This is of greatest importance from 
both the standpoint of prognosis and treatment. 

To form a definite conclusion we must consider the 
age of the infant, realizing that the age at which the 
infant becomes sick is of great importance, the previ- 
ous history of the infant as to diet and preceding nu- 
tritional disturbances and infections, together with a 
careful study of any existing constitutional anomalies or 
idiosyncrasies. In the consideration of the latter the 
family history as to serious nervous diseases, tubercu- 
lous infections, and the history of the result of previous 



NUTRITIONAL DISTURBANCES. 191 

pregnancies, are of extreme importance. Full considera- 
tion must be given to the surroundings under which the 
nutritional disturbance developed. Unhygienic conditions 
in the home are of the greatest importance. It is also 
well known that a greater tendency exists to develop- 
ment of this class of disturbances during long continued 
hospital and institutional confinement because of ex- 
posure to infection and lack of exercise. The season 
of the year should be considered in arriving at a con- 
clusion as to the underlying etiology. 

According to the school affiliation of the physician, 
one speaks of food injuries, basing his classification upon 
the etiological factor, while the other classifies them in 
the clinical light. Almost every year brings with itself 
new modifications in the presentation of the subject. 
Many of them do not lead to the goal of the practical. 

The clinical pictures which the nutritional disturbances 
of infants assume in their course are, to a certain extent, 
uniform, and in fact they can usually be included in cer- 
tain definite types. On the one hand are the acute and 
subacute disturbances, of which the most important 
symptoms are related to the gastro-intestinal canal, 
especially diarrhea with a tendency to more or less gen- 
eral disturbance, more particularly of the nervous system. 
In many of the chronic disturbances, manifestations on 
the part of the digestive tract may be entirely absent, 
and they almost never present a characteristic impression 
of the primary etiological factor. All of them have in 
common, signs of lowered immunity, abnormal behavior 
of the weight curve, alterations of the color and turgor 
of the skin. In fact the differences are likely to be quan- 
titative only. 

Thus, in both acute and chronic disturbances there are 
often very narrow limitations for the etiological diag- 
nosis, based upon clinical findings. And it is often dif- 
ficult to determine whether alimentary causes due to 
over- or underfeeding, recurrent infections or constitu- 



192 INFANT FEEDING. 

tional inferiority are the underlying factors. Knowing 
these limitations the importance of a carefully taken his- 
tory cannot be overestimated. The history of the pro- 
dromes, onset and development will frequently give the 
data necessary to differentiate between the primary ali- 
mentary disturbances and those secondary to infections 
and constitutional anomalies. 

All of the etiological possibilities are exhausted by 
(1) alimentation. (2) infection, (3) constitution, and 
(4) environment (weather and hygiene). Their sharp 
differentiation, however, is often difficult. 

And while a proper estimation of the degree of the 
nutritional disturbance may be gained from the history 
(determination of the preceding illnesses and the deter- 
mination of the development history of the present ill- 
ness), a detailed study of the actual picture, as pre- 
sented in the individual infant, as met by the physician 
in his daily practice, must form the basis for properly 
outlining the course of treatment. 

Even in those nutritional disturbances in which the 
etiological diagnosis is not only probable, but positive, 
the treatment is not based upon the etiology, but rather 
upon condition of the individual infant at the time of 
examination. Thus, if proper treatment of a case pre- 
senting diarrhea as the most marked symptom, was pos- 
sible only after we had the knowledge of the factors, 
which produced the diarrhea, the institution of proper 
therapy would in many instances, of necessity, be delayed. 

On the other hand, there are diseases, although symp- 
tomatically almost completely alike, varying widely in 
their course and response to the same treatment and in 
their final outcome. In other words, the individuality 
of the infant is often the deciding factor in the prog- 
nosis of the case. 

By exact clinical analysis we are able in most cases 
to arrive at a proper estimation of the degree of the 
nutritional disturbance and thus to the institution of the 



NUTRITIONAL DISTURBANCES. 193 

plan of treatment, and this object may be reached in 
almost every case by a study of the preceding history 
of the infant and by a consideration of the progress of 
the disturbance. 

We know that the bacteria and their products as en- 
countered in the food administered, are less often the 
offending factors than formerly supposed, and that im- 
proper food, either quantitatively or qualitatively, is of 
equal or greater importance in the causation of nutri- 
tional disturbances. To avoid confusion in our discus- 
sion of this vast field, we will first consider food injuries 
and discuss the infections incidentally, as they affect the 
former, and at a later period discuss the infections in 
their relation to the nutritional disturbances more in 
detail. 

From the foregoing it becomes evident that to discuss 
the whole subject properly it becomes necessary to con- 
sider them from both the etiological and the clinical 
standpoints. 

Etiological Classification of Nutritional 
Disturbances. 

1. Overfeeding with Milk Mixtures, of: 

(a) Correct composition (too frequent or too 

much ) . 

(b) Incorrect composition: 

(l)i With insufficient sugars. 
(2) With excess of fat, protein, sugar or 
salt. 

(c) Raw milk (with resulting mechanical irrita- 

tion due to large, hard protein curds). 

2. Underfeeding with Milk Mixtures of Correct Compo- 

sition. 

3. Underfeeding with Diets of Incorrect Composition. 

(a) Diets with insufficient milk and sufficient 
sugars. 

13 



194 INFANT FEEDING. 

(b) Diets composed chiefly or entirely of starches. 

(c) Diets low in vitamines. 

J t . Feeding with Spoiled Milk (Decomposition Products 

of Milk and Bacterial Toxins J. 
■'>. Subnormal Food Tolerance. 

(a) Preceding dietetic errors and nutritional dis- 

turbances. 

(b) Infections: 

( 1 ) Enteral : dysentery, typhoid, etc. 

(2) Parenteral: otitis, pharyngitis, pneu- 

monia, pyelitis, etc. 

(c) Extremes of temperature (heat of summer 

and cold of winter). 

(d) Improper hygienic conditions and "hospital- 

ism." 

(e) Constitutional anomalies: 

(1) Organic (pyloric stenosis, megacolon). 

(2) Functional (idiosyncrasy to cow's milk. 

Exudative diathesis. Neuropathic 
diathesis.) 

Nutritional Disturbances Due to Overfeeding. This 
is one of the most important of all etiological factors. 
The disturbance may be due to a diet of correct compo- 
sition, but quantitatively too great for the individual case, 
or a diet with an excessive amount of one or more con-' 
stituent ingredients. 

Nutritional Disturbances Following Underfeeding. 
We recognize two types: (1) Qualitative, and (2) quan- 
titative. Sooner or later the results are similar. The 
former diets, qualitatively wrong, are frequently seen 
where the caloric requirements are met, but one or more 
of the necessary food elements is insufficient. An ex- 
ample of this is seen in the feeding of carbohydrate rich 
food, as condensed milk, malted milk. etc. When the 
minimum requirements for growth and development, at 
least for both organic and inorganic salts, are met in such 



NUTRITIONAL DISTURBANCES. 195 

. a diet, the organism may be able to overcome the excess 
of one ingredient, but if this is not true, sooner or later 
some grave complications will result. With diets com- 
posed largely of cereals or cereal waters, as is frequently 
seen when these are used to replace the milk mixtures, 
in the course of diarrheal disturbances, the clinical pic- 
ture of inanition develops with great rapidity. When we 
feed less than a sustaining diet of 32 calories per pound 
body weight or 70 calories per kilogram, there soon re- 
sults a quantitative inanition with all its undesirable after 
effects. More recently we have learned to classify in- 
fants fed for prolonged periods on diets low in vitamines 
among those suffering from qualitative inanition. To 
judge such errors in diet, each individual infant must be 
studied as a distinct entity. 

Nutritional disturbances following feeding with 
spoiled milk may be due to decomposition products of 
milk, bacterial toxins or pathogenic organisms contained 
in the milk which may result in secondary enteral or 
parenteral infections. 

Nutritional Disturbances Due to Subnormal Food 
Tolerance. Many factors can cause such a state of 
affairs. The history of preceding dietetic errors and nu- 
tritional disturbances should be given careful considera- 
tion. Thus, e.g., diarrheal conditions, due to a given 
cause, will in the normal infant give a far better prog- 
nosis than in the infant which has suffered from over- 
or underfeeding, while in the athreptic infant even mod- 
erate diarrheal disturbance should give grave concern. 

Infections, enteral and parenteral will show marked 
individual differences in producing a subnormal food 
tolerance. The natural immunity of the healthy breast- 
fed infant affords the best example of the importance 
of a diet in the establishment of resistance to infection. 
The susceptibility to infection is increased by every 
nutritional disturbance as well as by constitutional 
inferiority. 



196 INFANT FEEDING. 

Most of the disturbances due to extremes of tempera- 
ture are noted in summer, during which season they are 
not only due to the effect of temperature upon the infant, 
but also due to spoiled food. Exposure to cold is often 
an etiological factor through lowering of immunity. 

Improper hygienic conditions in the home predis- 
pose to impairment of digestive functions as well as to 
secondary infections. In this connection it should be 
remembered that long continued hospitalization, even in 
the presence of good surroundings and proper diet, may 
result in lowered food tolerance due to lack of "mother- 
ing" and exposure to infection. 

Constitutional anomalies may result in various types 
of nutritional disturbances, depending upon their nature. 
In the presence of hypertrophic pyloric stenosis, quan- 
titative inanition, with resulting athrepsia, is likely to 
develop in uncorrected cases. In the presence of intes- 
tinal stasis, due to a weakened intestinal musculature, 
as seen in megacolon, and in the. course of severe rickets, 
a marked constipation develops, with retention of the 
intestinal contents for a prolonged period, both in the 
ileum and large intestine, with resulting absorption of 
the products of decomposition. Fortunately few infants 
show a true idiosyncrasy to cow's milk. This causes very 
great difficulty in feeding young infants in the absence 
of a supply of breast milk. The intolerance of infants 
suffering from exudative diathesis, to overfeeding as 
well as the tendency of neuropathic infants to develop 
exaggerated reflex action in the gastro-intestinal tract, 
with resulting cardio- or pylorospasm, and increased 
peristalsis of the intestinal tract with the development 
of colic and diarrhea, offer some of the most difficult 
problems in infant feeding. This group of cases calls 
for repeated observation and study of the individual 
infant. 



NUTRITIONAL DISTURBANCES. 197 

General Symptomatology. 

The normal healthy infant, with a well-balanced metab- 
olism, reacts to food as follows : 

1. An elastic, pink skin, a well-developed panniculus 
adiposus, well-colored mucous membrane. Its tissues 
should feel firm. 

2. One should expect certain muscle and bone develop- 
ment according to the age of the infant. 

3. A uniform rectal temperature (98 to 99 degrees F.), 
almost a monothermia. Any considerable deviation is 
abnormal. 

4. It should show a regular, steady gain in weight. 

5. The bowel movements should be regular, and should 
vary with the food ingested. 

6. Its disposition should be happy, and its nervous 
functions normal. It should sleep well, and be satisfied 
with feedings at three- to four-hour intervals. 

7. It should show a wide tolerance for food, both as 
to the diet as a whole, and to the individual food ele- 
ments. 

8. Renal, circulatory and respiratory functions should 
be normal. 

Bearing in mind the attributes of the healthy infant, 
we are now in a position to review the factors leading 
to and influencing our present conceptions of the nutri- 
tional disturbances, based on an ascending series of 
pathological stages in those infants whose tolerance for 
food has been overstepped, either because of overfeeding 
or because of diminished or abnormal tolerance on the 
part of the baby itself. 

The clinical observation soon convinces one that while 
simple types are not uncommon, mixed and progressive 
types are of frequent occurrence. Exact observation of 
variations in the general condition of the infant and the 
correct interpretation are necessary for a proper under- 
standing of the clinical symptoms. A correct diagnosis 



198 INFANT FEEDING. 

of a condition can usually be made from the clinical 
analysis of the symptoms with the aid of the previous 
history. In order to outline the proper plan of treat- 
ment, it is necessary to decide whether in a case under 
observation tbere is a mild or a serious disturbance. 
This is of the greatest importance in the choice of good 
mixtures, both in qualitative and also in quantitative re- 
spect. The physician needs to learn that the condition 
of the infant should not be estimated by any single clini- 
cal symptom, but rather according to the effect upon the 
general condition of the patient. He must take into con- 
sideration the weight curve, the color of the skin, the 
muscle tone and turgor, the presence of anemia, the state 
of the sensorium, and the condition of the stools, and 
in addition to these any other symptoms which may de- 
velop. As an example, he should not consider only the 
presence of diarrhea, but even more important, the re- 
action of the infant to the loss of body fluids and salts 
through excessive stools. He should remember that age 
is an important factor and that nutritional disturbances 
in the first three months of life should always be re- 
garded as serious, in other words, a diarrheal condition 
in the first six weeks of life is far more serious than 
the one developing in the sixth month of life. The dis- 
turbance in the infant whose history shows that there 
is nothing defective in his constitution, allows of a bet- 
ter prognosis than would be expected in a weakling. By 
exact clinical analysis we are able in most cases to ar- 
rive at a proper estimation of the degree of nutritional 
disturbance and thus to institute a plan for treatment. 

Clinical Classification of Nutritional 
Disturbances. 

In the clinical pictures that may develop on the basis of 
the above-mentioned etiology, several more or less dis- 
tinct types or syndromes may be differentiated. These 



NUTRITIONAL DISTURBANCES. 199 

may be dependent primarily or exclusively upon the die- 
tetic errors, or they may be influenced by secondary etio- 
logical factors. The degree of reaction depends upon 
the extent to which the infant's metabolism is disturbed. 
For practical purposes of diagnosis and treatment the 
nutrition disturbances may be grouped on a clinical ba- 
sis, as follows : 

1. Nutritional Disturbances Unassociated with Diar- 
rhea. 

2. Nutritional Disturbances Characterised by Diar- 
rhea. (Diarrheal disturbances.) 

3. Athrepsia (Marasmus. Decomposition). 

J+. Anhydremia (Anhydremic intoxication. Intoxica- 
tion.) 

These types represent stages in the course of nutri- 
tional disturbances and one form may lead rapidly into 
another, if the errors in the diet are not remedied, or 
when secondary complications, such as infections, arise. 



CHAPTER III. 

NUTRITIONAL DISTURBANCES UNASSOCIATED 
WITH DIARRHEA. 

Overfeeding with Cow's Milk with Insufficient 
Carbohydrates. 1 

The syndrome to be described under this cause ap- 
pears in the pediatric literature under various synonyms. 
Among them are the following: 

Disturbed metabolic balance, weight disturbance, mal- 
nutrition, hypothrepsia (Parrott), hypotrophy (Lang- 
stein), fat constipation, bilanzstoerung (Finkelstein), 
milchnahr schaden ( Czerny-Keller ) . 

This nutritional disturbance is due to administration 
of cow's milk mixtures in which the error is based upon 
an excess of cream or milk in the diet in the presence 
of an insufficiency of sugar. A disturbance in the 
metabolic balance is rarely seen in the previously nor- 
mal infant until the amount of cow's milk fed is in ex- 
cess of two ounces (60 mils) per pound body weight. 
With this amount of milk the average requirement in 
sugar to be added will be one-tenth ounce (3.0 Gm.) 
for each pound of the infant's weight. 2 The clinical 
signs develop slowly in most cases and follow a period 
of good progress which ceases more or less abruptly. 
Among the early signs are a general retardation of de- 
velopment, associated with a loss of body turgor and 
stationary weight. The severity of the clinical picture 
will depend upon the ability of the individual infant to 



1 In the first and second editions these cases were described 
under the title of Disturbed Metabolic Balance. 

2 It should be remembered that a well-balanced 24 hour diet 
for an infant should rarely contain more than one quart (1000 
mils) of cow's milk and from V/-> to 2 ounces of sugar (45 to 
60 Gm.). Further nutritional requirements are to be met by 
the addition to the diet of foods other than milk and sugar. 

(200) 



DISTURBANCES WITHOUT DIARRHEA. 201 

overcome the ill effects of the one-sided diet and this 
will vary directly with the degree of the error and the 
time over which the diet has been administered. The 
diagnosis must be based on the presence of symptoms 
resulting in definite injury to the organism. Not infre- 
quently the diagnosis is made upon the presence of 
marked constipation with a passing of soap stools. These 
are dry and putty-like, have a foul odor and an alkaline 
reaction. It must be emphasized that the diagnosis of 
this nutritional disturbance, due to an improperly bal- 
anced cow's milk mixture, must not be based upon the 
presence of soap stools alone. This is the characteristic 
stool seen in feeding, even when the milk is not in ex- 
cess of the amount on which the infant will make normal 
progress. 

Etiology. Artificially fed infants are chiefly affected, 
probably because of the high carbohydrate and low pro- 
tein content in the breast-milk. 

The clinical picture presented by this type of over- 
feeding, which is due to an improperly balanced diet, 
is usually seen in infants receiving food mixtures com- 
posed of cream and milk, top-milk or whole milk with 
an insufficiency of carbohydrates, resulting in an im- 
proper proportion between the fat and carbohydrates in 
the diet. In the presence of excessive amounts of carbo- 
hydrates we are more likely to see a diarrheal condition. 
Proteins also play an important role in the causation of 
the clinical picture of this disease, in that in the presence 
of a relative overfeeding with proteins an alkaline intes- 
tinal reaction, necessary to the production of fat-soap 
stools, is brought about. Not all infants react alike to 
the same milk mixture, and those who have a low toler- 
ance for milk, as is the case with many of the infants 
suffering from exudative diathesis, develop the clinical 
picture much earlier than the average infant. The same 
may be said of the lowered food tolerance following in- 
fections. Fortunately in these infants the tolerance for 



202 INFANT FEEDING. 

carbohydrates is retained and therefore the fat and the 
protein in the diet can, to a great degree, be replaced by 
sugar and cereals. It should be remembered that these 
infants suffer from a carbohydrate poverty or deficiency 
and therefore in the presence of infections and other 
complications there is an urgent indication for a high 
carbohydrate feeding. 

Pathogenesis. As soap stools are so frequently re- 
garded as the basic symptom in the diagnosis of this dis- 
turbance, their significance will be emphasized. The 
soap stool must be viewed as an effect and not as the 
cause. The condition is not due to a fat indigestion, but 
a disturbance in salt metabolism based on an improper 
composition of the diet in which there is a relative over- 
feeding with fat and protein in the presence of insuf- 
ficient carbohydrates. The stools consist largely of cal- 
cium and magnesium soaps formed from the fatty acids. 
The presence of the relatively large amounts of calcium 
caseinate in cow's milk leads to an alkaline condition in 
the intestinal tract which reaction increases the tendency 
toward their formation. These stools also contain large 
amounts of calcium phosphate, which in the presence of 
the alkaline reaction of the intestinal tract are rendered 
insoluble. The organism may be markedly affected 
through the lack of absorption of bases and excessive 
loss of alkalies by increased intestinal secretion. Many 
infants will overcome the ill-effects for long periods of 
time without clinical evidence. Others will present evi- 
dences of retarded growth, resulting in malnutrition. 
Rickets may result. The alkalies most involved in the 
formation of the soap stools which are so commonly seen 
in this condition are calcium and magnesium. There is, 
however, also a decreased sodium and potassium reten- 
tion, as evidenced more especially by increased excretion 
in the urine. This loss of calcium and magnesium 
through the stools and the inability to retain sodium and 
potassium, and the accompanying decrease in water re- 



DISTURBANCES WITHOUT DIARRHEA. 203 

tention, soon lead to weight loss. The soap stools, as 
stated, contain an excess of calcium and magnesium 
soaps, and less fatty acids and neutral fats than is seen in 
the normal stools. 

To obtain such a stool, there must be a strong alkaline 
reaction in the large intestine, and the food elements of 
the diet are important factors in the production of this 
reaction. 

Fats. An excess of fats in the food leads to an ex- 
cess of fatty acids in the intestine, with a tendency to 
the formation of an acid reaction of the intestinal con- 
tent. To combine with these, alkalies are withdrawn 
from the body, if insufficient in the intestinal tract. 

Proteins, more especially an excess of calcium casein- 
ate, cause secretion of a large quantity of intestinal juice 
which is alkaline. This in time tends to produce an al- 
kaline intestinal reaction, if not counteracted by exces- 
sive fermentation, the former being favorable to the 
formation of soap stools. In all probability the great 
calcium content of cow's milk (4 to 1), as compared 
with breast-milk, also offers another factor in the ten- 
dency to formation of calcium soaps. 

Carbohydrates. In the presence of sufficient ferment- 
able carbohydrates (disaccharides) in the diet, the in- 
testinal reaction becomes acid, the products of fermen- 
tation counteracting the tendency to alkaline reaction, 
and thus preventing the formation of fat-soap stools. 

The decreased absorption of bases and the increased 
withdrawal of alkalies from the system disturbs the acid- 
alkaline equilibrium, creating a relative excess of acids. 
This results in an increased production of ammonia to 
counteract the loss of alkali in order to prevent acidosis. 

We find a striking example of a paradoxical reaction, 
namely, increasing the food (milk or fat) makes the 
condition worse and causes weight loss, while diminish- 
ing the milk with an increase in carbohydrates results 
in return to normal. 



204 INFANT FEEDING. 

The clinical picture is due to : 

1. Excessive withdrawal of salts from the body tis- 
sues, due to fat and protein overfeeding. 

2. A relative insufficiency of carbohydrates. 

3. Bacterial decomposition of food in the intestinal 
tract. 

As previously stated, the fat-soap stools must not form 
the basis for diagnosis. It must be based upon the study 
of the feeding history, clinical signs and in some cases 
the constitutional anomalies and systemic infections as 
predisposing causes. On the whole, this clinical syn- 
drome is not as frequently seen as might be expected, 
because of the ability of the infant to overcome the 
dietetic error sufficiently to make a fair progress. 

Symptoms. There is a retarding of development 
qualitatively and quantitatively, the infants frequently 
being undersized, without showing marked general symp- 
toms of disease. 

1. Weight. Notwithstanding proper or even excessive 
caloric intake, there may be no gain in weight, or an 
irregular increase, however, under the normal. (Station- 
ary weight or insufficient gain in the infant corresponds 
to a loss in weight in the adult. Stationary weight in 
an infant alone leads to the picture of malnutrition and 
marasmus.) 

2. Temperature. Usually we find daily oscillations 
from 1° to 2°, with a tendency toward subnormal. 

3. The child is restless. 

4. Sleep is disturbed. 

5. The skin is pale, with loss of elasticity and turgor. 
Intertrigo and eczema are frequently seen. 

6. Muscles are soft and flabby. 

7. Regurgitation and vomiting are frequent. 

8. Abdomen, tympanitic. 

9. Stools. In excessive milk feeding the common type 
is the fat-soap stool, which is foul-smelling, dry, light in 
color (gray to white), friable, and does not stick to the 



DISTURBANCES WITHOUT DIARRHEA. 205 

napkin. The pale color is due to the reduction of biliru- 
bin to urobilinogen. The odor, in part at least, is due 
to the decomposition of protein. The large, putty-like 
masses of stool are moved through the lower intestinal 
tract with difficulty, even in the presence of active peri- 
stalsis. This interferes with emptying of the intestine, 
the stools becoming very dry through the absorption of 
moisture due to this long period of retention. Not in- 
frequently their progress through the colon is associated 
with colicky pains. In the presence of excessive carbo- 
hydrates this stool may be lacking, due to the presence 
of a slight intestinal indigestion. Occasionally bacterial 
decomposition of the proteins may cause a diarrhea. 

10. Immunity is lessened with resulting furunculosis 
and susceptibility to respiratory, gastro-intestinal, and 
genito-urinary! infections. 

11. Urine is usually ammoniacal, and contains an ex- 
cess of sodium and potassium salts. The fact that alka- 
lies, found as soaps, are poorly absorbed from the intes- 
tine makes it necessary for the body to produce ammonia 
to make up for the deficit and to prevent acidosis. This 
explains the excess of ammonium salts in the urine. The 
salts are decomposed after passage of the urine by com- 
ing in contact with bacteria. The freeing of ammonia 
by the bacterial decomposition can be prevented by rins- 
ing the napkins after boiling and washing in a %o>ooo 
solution of bichlorid of mercury, the deposited mercurial 
salt preventing bacterial growth after the urine comes 
in contact with the napkin. 1 

Diagnosis. Due to the fact that this type of stool 
with associated constipation is so frequently seen in 
artificially fed infants, it is difficult to say just when 
such constipation becomes pathologic. As long as the 
infant is making satisfactory progress and showing no 



1 Cooke, J. V. : Etiology and Treatment of Ammonia Dermati- 
tis of the Gluteal Region of Infants, Amer. Jour. Dis. of Children, 
xxii, 481, 1921. 



206 INFANT FEEDING. 

signs of definite pathology the mere presence of soap 
stools should be considered as of relatively slight im- 
portance and should not lead to radical changes in the 
diet. 

The diagnosis must be based on the clinical picture 
and feeding history, as follows : Sufficient caloric intake 
(100 calories per kilogram), with relative excess of fat 
and protein, and insufficiency of carbohydrates, station- 
ary weight or insufficient gain, loss of turgor, lack of 
proper development, and usually soap stools, all in the 
absence of any other causative factor. Underfeeding 
and all past illnesses which might retard development 
must be excluded. 

Prognosis is very favorable in uncomplicated cases, 
with a properly instituted diet. In the average case two 
to three weeks is required to overcome the constipation, 
and to obtain a gain in weight. Occasionally a severe 
type is seen which is difficult to overcome, most com- 
mon in infants with an idiosyncrasy to cow's milk. 

Complications. Because of the lowered immunity, 
infections are common, especially of the nasopharynx, 
lungs, middle ear and skin and gastro-intestinal and 
genito-urinary tract. Exudative diathesis is not an un- 
common associated condition. 

Sequelae. This condition is often the forerunner of 
the more serious nutritional disorders, such as diarrhea, 
athrepsia, and anhydremia. Chronic constipation fre- 
quently results, due to the atony of the intestinal wall 
and abdominal muscles. Rickets frequently develops in 
these infants. 

Treatment. To institute a proper treatment, we 
must remember that the clinical picture is not dependent 
on gastro-intestinal findings only, but also on an abnor- 
mal intermediary metabolism (therefore the designation 
Disturbed Metabolic Balance), and that fat overfeeding 
primarily, and a carbohydrate insufficiency secondarily, 



DISTURBANCES WITHOUT DIARRHEA. 207 

are causative factors, and that protein overfeeding may 
be an important element. 

1. Diet with Human Milk. This is by all means the 
best treatment, especially in young infants. Weight in- 
crease may be slow at first, probably due to low salt and 
protein content of human milk. A loss of more than 6 
to 10 ounces over a period of three or four days is fre- 
quently seen. More than this should lead one to suspect 
an error in diagnosis. This loss may be due, as stated, 
to stopping of a food rich in proteins and salts, and sub- 
stituting one low in the same. This stage is passed in 
about four days, when the system adapts itself to the new 
food ingredients. Temperature and pulse do not change, 
and the stools assume a breast-milk-stool character. If 
the stage of reparation is slow, and the child does not 
gain in weight, the substitution of one meal rich in pro- 
tein and salts daily will frequently help (buttermilk or 
skim milk). Mother's milk also helps to increase the 
immunity. 

2. Diet with Artificial Foods. In pathogenesis of this 
condition the milk plays the most important role, and 
this is best counteracted by replacing it in part, with well- 
tolerated carbohydrates. 

( 1 ) In simple cases reduce the quantity of milk and 

add carbohydrates in the form of sugar and 
starches. 

(2) In severe cases; 

(a) Malt soup (Keller's) (p. 437) is exceedingly 
valuable. Malt soup is indicated in the 
presence of fat-soap stools which soon be- 
come pasty and of mahogany-brown color; 
the best results with malt soup are obtained 
in infants from three to six months of age. 
After four months more milk than given in 
the original formula must be added to in- 
crease the protein content of the diet. 



208 INFANT FEEDING. 

(b) Buttermilk or skim milk mixtures (contain- 

ing two carbohydrates, i.e., sugar and 
flour). The action of both is the same. 
Occasionally it is necessary in young in- 
fants to reduce the sugar recommended in 
the original formula (see Buttermilk Mix- 
ture, p. 436). 

(c) Brady's buttermilk mixture No. 1 (p. 436). 
Change of the diet is followed by better sleep, im- 
proved turgor, skin becomes less pale, less variation in 
temperature. Stools change from soap stools to (1) yel- 
low-brown, alkaline and fair consistency, when butter- 
milk mixtures are fed, (2) acid, softer, mahogany- 
brown color when malt soup is fed. 

These results of treatment are due to the fact that the 
tolerance for carbohydrates is high, and protein toler- 
ance is little impaired. Each case should be watched to 
see if an excess of carbohydrates is not being given in 
the new diet, which is indicated by (a) restlessness, (b) 
stopping of weight increase after an early rise, (c) ali- 
mentary fever (irregular), (d) too frequent stools. If 
the cow's milk mixtures are not well tolerated, human 
milk is indicated. 

The above mixtures should be gradually replaced by 
ordinary milk mixtures after two to eight weeks. 

In infants over six months of age one of the most con- 
stant and brilliant therapeutic results follows the use 
of a limited amount of milk (boiled or citrated) and the 
free administration of toast, zwieback, rusk, and cooked 
cereals given in increasing quantities up to amounts that 
will bring on a steady gain of 6 to 8 ounces a week. To 
this diet broth or vegetable soup and orange juice should 
be added soon. In other words, if a baby of six or seven 
months does not gain on ordinary milk mixtures, it should 
be fed like a normal baby of nine or ten months, with 
the single exception that the milk should be kept rather 
low, or at least given cautiously, and preferably boiled 



DISTURBANCES WITHOUT DIARRHEA. 209 

or citrated, or both. In many cases this can be done 
even in the fifth month. 

Underfeeding with Cow's Milk Mixtures of 
Correct Composition. 

The cases of this class include those infants receiv- 
ing a diet containing a proper proportion of the neces- 
sary food ingredients, however, in insufficient quantity. 
(Too little of a proper food.) These must again be 
divided into two groups: 

(a) Normal Infants Quantitatively Underfed. In 
breast-fed infants this group is more common than in 
artificially fed. And while in the artificially fed such 
cases are occasionally seen, this is a far less frequent 
condition than overfeeding. Because in the normal in- 
fant hunger is manifested by crying, restlessness, loss 
of weight and associated constipation, which fortunately 
in most instances leads to a proper interpretation, result- 
ing in increase of the diet. 

(b) Infants Suffering from Nutritional Disturbances, 
Quantitatively Underfed. These cases are the ones 
which so frequently suffer from quantitative inanition, 
due to the fact that the fever, vomiting and diarrhea 
offer every indication for a reduction in diet, or a starva- 
tion diet. While this leads to an improvement in the 
general symptoms, the remaining hunger stool, because 
of its greenish-brown color and excess of mucus, is not 
uncommonly interpreted as a diarrheal stool, leading to 
prolonged starvation and not infrequently repeated 
catharsis. 

The result of repeated starvation must necessarily be 
a condition of malnutrition, which sooner or later will 
result in the stage of athrepsia (marasmus), unless the 
underlying condition is corrected, and a proper diet 
instituted. 

Treatment. Repeated hunger days and long-con- 
tinued underfeeding should be instituted only upon defi- 

14 



210 INFANT FEEDING. 

nite indications, the sudden decrease in the food leading 
regularly to weight loss and lowered food tolerance. 

An initial cathartic is frequently indicated, while re- 
peated catharsis is harmful. 

The diet should be as rapidly increased as the infant's 
condition will tolerate. It should be carefully selected 
to meet the requirements of the individual infant. 

While in mild cases a properly selected diet leads to 
rapid recovery and gain in weight, in the severe cases 
we not infrequently see a paradoxical reaction to food, 
necessitating feeding as described under the chapter on 
Athrepsia. 

In every case the infant's tolerance to food should be 
carefully studied, and increases made only as tolerance 
permits. 

Hunger stools are rapidly replaced by those of normal 
consistency in the presence of a proper diet. 

Underfeeding with Diets of Incorrect 
Composition. 

(a) Diets with Insufficient Cow's Milk and Suf- 
ficient or An Excess of Sugars. This class of cases 
are most frequently seen in infants fed on proprietary 
foods, more especially condensed milk and the so-called 
"baby foods" composed largely of carbohydrates to which 
some milk is added. 

The tendency on the part of the infant so fed is to 
store large amounts of fat. They usually appear plump, 
but have a tendency to develop secondary anemia, rickets 
and scurvy. Frequently diarrhea will be superimposed 
in the presence of slight irritation of the gastro-intestinal 
tract following mechanical or bacterial causes. 

Infants fed upon such one-sided diets have a lessened 
immunity, both to systemic and intestinal bacterial in- 
fections. They are therefore liable to recurrent infec- 
tions. 



DISTURBANCES WITHOUT DIARRHEA. 211 

Treatment. The chief object should be to place them 
upon a well-balanced milk mixture suitable to their age, 
to which well-cooked cereals and vegetables are to be 
added as the age permits. 

In changing to cow's milk mixtures from these high 
carbohydrate diets, it is best to start with small amounts 
of milk first, adding one ounce of cow's milk for each 
pound of body weight. This is to be increased as the 
infant's condition permits. The carbohydrates should 
be reduced to amounts approximating one-tenth ounce 
per each pound of body weight, in addition to that con- 
tained in the milk. Only in the presence of severe diar- 
rhea should sugars be entirely withdrawn and then with 
caution, because of the danger of collapse. It is advis- 
able to boil the mixture, at least early in the new feeding, 
in order to split the casein curds. The semisolids should 
be added gradually and increased as indicated after the 
infant has shown its ability to first handle the milk 
mixture. 

(b) Diets Composed Chiefly or Entirely of Starches. 
Synonyms: Flour injury, starch injury, mehlnahrschaden 
( Czerny-Keller ) . 

Etiology. The condition follows feeding with a diet 
composed largely of cereals or cereal waters, as is fre- 
quently seen when these are used to replace milk mix- 
tures which have been poorly digested (diarrhea, etc.). 
It is therefore due to continued feeding of flour gruels, 
either without milk or a diet too low in milk content. 
Whether simple flour or baby foods, dextrinized or not 
are used, the result is the same. Although the flour in 
its digestion is changed to sugar, the effects are not those 
of excessive sugar diet (acute), but only lead to acute 
symptoms after the organism has been generally im- 
paired by the long use of the one-sided diet. 

Pathogenesis and Metabolism. The disturbance of 
the organism which develops on one-sided flour feeding 
is to be regarded as qualitative inanition, being due to 



212 INFANT FEEDING. 

the lack of important tissue-building substances (fat, 
proteins, salts and vitamines ) , and the resulting improper 
formation of the body tissues. 

Steinitz and Weigert found in animals that a flour diet 
led to an abnormal chemical composition of the organ- 
ism. The body became richer in water and fat than nor- 
mal. The edema indicates a disturbance in the salt 
balance. Marriott believes that lack of fat-soluble vita- 
mines is an important etiological factor. 

In many cases, also, the caloric intake may be insuffi- 
cient, so that quantitative inanition complicates the pic- 
ture. The accumulation of large quantities of water 
which occurs when large quantities of flour are fed in 
presence of salts results in fluctuations in weight. 

Rapidity of development depends on the following 
factors : 

1. Age. The younger the child, the quicker the effects 

2. The more the flour outweighs the other ingredients 
of the diet. 

Symptoms. They may assume any form of nutri- 
tional disturbance. In many cases apparent symptoms 
of disease are lacking for a long time in spite of the 
improper diet. The infant may even apparently thrive 
well, since (due to the great water-binding property of 
carbohydrates) considerable gains in weight may occur. 
The appearance of the child is good, and fat cushion 
abundant. Even at this time, however, frequently some 
anomalies are observed : the musculature may be slightly 
hypertonic, the appearance may be pasty, suggesting a 
water-soaked sponge. Not infrequently by careful exam- 
ination nervous irritability (latent tetany) may be de- 
tected. This is followed by development of grave symp- 
toms of typical flour injury, which may assume variable 
appearance, according to whether the flour is given alone 
or combined with some other food. 

Flour has the property of causing the body to take on 
weight by water absorption. This is especially true if 



DISTURBANCES WITHOUT DIARRHEA. 213 

the infant was previously healthy, and may be mislead- 
ing. In infants suffering from nutritional disturbances 
the picture develops more rapidly, especially upon in- 
auguration of repeated starvation diet. Finally, how- 
ever, both these groups of infants present the picture of 
an inanition — that is, the atrophic stadium, which cannot 
be distinguished from a decomposition clinically. They 
are subject to rapid weight and water losses, showing the 
loose binding of the water in the tissues. 

Edema may complicate the picture, especially where 
the flour is given in a salt-rich diet as bouillon, milk, etc., 
and the edema may resemble that of a nephritic patient 
(urine is usually negative). 

The natural immunity in these hydremic conditions is 
greatly reduced, and the children are subject to furun- 
culosis, otitis, and infections of the respiratory and diges- 
tive tracts, all of which give a bad prognosis. 

Hypertonia is very common, with a characteristic mus- 
cular rigidity, resulting in stiffening of extremities, opis- 
thotonos, etc., and it is often difficult to differentiate 
them from cases of spastic cerebral paralysis and chronic 
tetany, from which latter these infants often suffer. 
The history of nerve irritability must be used as a point 
of differentiation. 

Hypertonic form has also been described, the chief 
symptom of which is the rigidity of the muscles. This 
hypertonicity may occasionally assume such proportions 
that the limbs and the entire body may become rigid. 
But this condition is not exclusively caused by flour in- 
jury, but- may be seen also in other nutritional dis- 
turbances. 

Stools. Often the stools are good for a long time, 
but sooner or later in all cases acute intestinal symptoms 
develop. More characteristic, after continued feeding on 
a one-sided flour diet are soft, mushy, loose stools, which 
are frequent, and vary in color from brown to yellow. A 
further -characteristic is a tendency to fermentation, with 



214 INFANT FEEDING. 

the formation of acids and gas, which tend to irritate the 
buttocks. The small, dark-brown stools, composed 
mainly of mucus (hunger stools), are not infrequently 
seen, and are of especial significance, because they are 
often misinterpreted as dyspeptic stools. 

Diagnosis. The feeding history is of the utmost 
importance. Hypertonia and edema should lead to sus- 
picion, as should the presence of excessive fermenta- 
tion and "hunger stools." 

Prognosis. The younger the infant and the longer 
the unsuitable diet has been continued, the worse is the 
prognosis. The high mortality in this condition is due 
not so much to the nutritional disturbance itself, but 
more so to unavoidably complicating infections. Tetanies 
and convulsions due to them are also grave complications. 

Prophylaxis. The development of a primary flour 
injury is prevented by ordering proper diet. In using the 
flour diet for therapeutic purposes in the treatment of 
dyspepsia, especially when repeated starvation is in- 
augurated, the danger of development of the flour injury 
must be kept in mind, and the one-sided diet must not 
be continued longer than several clays. 

Treatment. 1. Human Milk. In young infants and 
also in all severe cases, feeding with human milk offers 
the best hope for the cure of the condition. It is abso- 
lutely indicated (1) before the third month, (2) in evi- 
dence of decomposition. 

Begin with 200 to 300 mils daily, as in decomposition, 
and continue, even with weight loss and development of 
dyspeptic symptoms. Increase the amount steadily. 
Even with human milk the course will be slow, if the 
condition is well advanced. 

2. Artificial Feeding. One-half boiled skim or whole 
milk plus water in feedings of 10 times 30 mils with water 
or tea ad libitum. Continue feeding, gradually increasing, 
unless the stools are dyspeptic. It is of advantage to 
hasten convalescence by addition of some sugar or mal- 



DISTURBANCES WITHOUT DIARRHEA. 215 

tose-dextrin preparations to the milk mixture. Albumin 
milk and buttermilk mixtures are often taken to better 
advantage than whole milk mixtures. If they fail, hu- 
man milk must be given. Codliver oil and orange juice 
should be started early in treatment. 

If stools retain fat-soap character after 10 to 14 days, 
the diet may be more rapidly increased. 

Course is often interrupted by weight drops and in- 
fections. 

In very severe cases in which symptoms of athrepsia 
are present, same treatment as in athrepsia should be 
instituted. 

(c) Diets Low in Vitamines. It is a well-known fact 
that even in the presence of diets containing proper 
amounts of fats, proteins, carbohydrates, mineral salts 
and water, retardation in the development and growth 
of the body may occur. This is frequently due to the 
lack of unidentified substances which are essential to 
life and which are described, for want of a better term, 
as vitamines. (See page 18.) 

Beriberi, pellagra, scurvy and rickets may be wholly 
or partially dependent upon a lack of vitamines for their 
development. The so-called flour injury is also, in 
part at least, due to a lack of vitamines. 

More recently it has been shown that many infants 
suffering from malnutrition and marasmus show a 
marked and rapid improvement in their general condi- 
tion when foods rich in vitamines, more especially water- 
soluble B and C, are added to their diets in increased 
amounts. 

Beriberi has positively been identified as a disease due 
to an insufficiency in water-soluble B vitamine. 

Pellagra is in all probability a deficiency disease, al- 
though there is still considerable question, as to whether 
other factors may not be contributing. 

Scurvy, judging from its prompt response to treatment 
with the water-soluble C vitamine, is undoubtedly a de- 



216 INFANT FEEDING. 

ficiency disease, even though in many instances it does 
not become clinically evident until precipitated by sec- 
ondary factors, such as an infection. (See page 35^.) 

Rickets. The pathological changes in the osseous and 
muscular system are undoubtedly due to the inability to 
utilize calcium, with a resulting diminished retention of 
this element, notwithstanding the fact that there may be 
a sufficient amount in the food intake and in the blood. 
Phosphorus probably plays an intermediate role in in- 
fluencing the deposition of lime salts. It is quite prob- 
able that a fat-soluble vitamine is a factor in determin- 
ing the level of the blood phosphate and thereby directly 
influences calcium retention. 

Subacute and chronic infections, more especially of 
the respiratory tract, are seemingly influenced by ad- 
ministration of cod-liver oil, which is high in fat-soluble 
vitamine and which leads to the deduction that it has 
a more or less direct influence in raising the immunity 
through some unknown factor. 

Treatment. The administration of diets properly 
constituted for the treatment of rickets is discussed on 
page 331 and scurvy on page 379. 

In the presence of retarded growth fat-soluble A vi- 
tamine is best administered in the form of cod-liver oil, 
and water-soluble B and C vitamines, as contained in 
fresh fruit juices, more especially in oranges, and fresh 
vegetables, more particularly the green-leaf variety, are 
indicated. 1 2 The infant's age permitting, orange juice 
should be administered in amounts equal to one to two 
ounces daily. 3 In a considerable number of this type of 
cases we have found the administration of one-half to 
one cake of fresh yeast daily of great value. It may 
be given in the orange juice or made into a paste with 



1 Karr, W. G.: Jour. Biol. Chem., 44, 255, 1920; 44, 277, 1920. 
-'Osborne, J. B.: Medical Record, 97, 630, 1920. 
3 Byfield, A. E. : Daniels, A, L., and Loughlin, R. : Am. Jour. 
Dis. Children 19, 349, 1920. 



DISTURBANCES WITHOUT DIARRHEA. 217 

butter or mixed with the fruit pulps, such as prunes or 
bananas. The paste may be spread on bread or crackers. 
When given in this way there is usually little objection 
to taste on the part of the infants. The same line of 
treatment is effective during the convalescence from 
acute infections and other debilitating diseases, and in 
the course of chronic infections. 



CHAPTER IV. 

NUTRITIONAL DISTURBANCES CHARAC- 
TERIZED BY DIARRHEA. 
(Diarrheal Disturbances.) 

The following conditions, characterized by diarrhea 
as the most prominent symptom, are described in the 
literature : Acute intestinal indigestion, fermentative 
diarrhea, infectious diarrhea, dyspepsia, stadium dyspep- 
ticum, sugar indigestion (zuckernaehrschaden), fat in- 
digestion (fettnaehrschaden), gastro-enteritis, summer 
complaint, cholera infantum, follicular-enteritis, mem- 
braneous-colitis. 

Etiology. Diarrhea may develop either primarily 
in a healthy infant or a sequel to preceding nutritional 
disturbances or it may be secondary to an infection. 

Diarrhea occurs as a symptom of many conditions of 
different etiology. Usually it is unassociated with demon- 
strable pathological lesions of the intestinal tract, and 
unfortunately these are the types most frequently seen. 
Anatomical lesions in the intestine, more especially in 
the lower ileum and large intestine, are constant find- 
ings in some of the infectious types and may be present 
in the subacute and chronic diarrheas, non-infectious in 
origin. 

The most important factors may be enumerated as 
follows : 
1. Overfeeding With: 

(a; Milk mixture of correct composition (too fre- 
quent or too much). 

(b) Milk mixture of incorrect composition (excess 

of fat, sugar or salt). 

(c) Raw milk, with resulting mechanical irritation 

due to large, hard protein curds. 
(218) 



DISTURBANCES WITH DIARRHEA. 219 

2. Feeding with Spoiled Milk (decomposition products 

of milk and bacterial toxins). 

3. Subnormal Food Tolerance Due to: 

(a) Preceding dietetic errors and nutritional dis- 

turbances. 

(b) Extremes of temperature, heat of summer and 

cold of winter, with resulting systemic de- 
pression. 

(c) Constitutional anomalies: 

1. Idiosyncrasy to cow's milk. 

2. Exudative diathesis (eczema). 

3. Neuropathic diathesis. 

4. Organic diseases of the heart, kidneys, 

liver and pancreas. 
Jf. Infections: 

1. Enteral. 

2. Parenteral. 

5. Cathartics (excessive and repeated administration). 

Very frequently several causes are combined in a sin- 
gle case, and it often becomes impossible to make an 
exact etiological diagnosis. In all varieties of diarrhea 
there are functional disturbances, and in the severe forms 
organic changes may be present, or the latter may de- 
velop in the course of an uncorrected case which at first 
was only functional in nature. An insufficiency of the 
intestines may soon be reached, which makes it impos- 
sible to avoid the development of pathological fermenta- 
tion and leads to an interference with absorption of 
water and the products of digestion, with the early de- 
velopment of systemic derangement. The abnormal 
products of fermentation cause increased peristalsis and 
result in an aggravation of the condition unless cor- 
rected. Interference with the normal function of secre- 
tion leads to changed bacterial content in the intestines. 
It is, therefore, often impossible to determine whether 
this changed bacterial flora, as evidenced in the feces, 
is the cause or result of the condition. 



220 INFANT FEEDING. 

Pathogenesis, The development of this group of 
disturbances will vary directly with the underlying causa- 
tive factor or combination of causes. 

Those Due to Overfeeding: With Milk Mixtures of 
Correct Composition. In this group vomiting and evi- 
dences of gastric and intestinal indigestion usually pre- 
cede the appearance of diarrhea. In fact, many of the 
cases are unassociated with diarrhea, the infant present- 
ing sufficient evidence of distress to call for reduction 
in diet before the latter stage is reached. The symptoms 
may be due to incomplete emptying of the stomach be- 
tween feedings when the intervals between meals are 
too short, or they may follow overfeeding when too 
large or too concentrated a diet is fed. Sooner or later 
intestinal symptoms will develop unless the dietetic error 
is corrected, due to bacterial action on unabsorbed food 
in the intestinal tract. 

In the second group due to overfeeding with milk 
mixtures of incorrect composition, any one or a com- 
bination of the food elements when in excess may pre- 
cipitate a diarrheal disturbance. By far the largest num- 
ber of cases as seen in practice fall within the limits of 
this group and we will discuss it more in detail because 
of the frequency with which it is met. The protein is 
not a good culture medium for the organisms commonly 
associated with the diarrheal diseases and, therefore, 
when fed in boiled mixtures, is not a common causative 
factor. On the contary, when casein is fed in sufficient 
amounts, in boiled, whole or skim milk or in dry forms, 
it counteracts pathological fermentation in the intestinal 
tract and the casein has a direct curative influence, 
as seen in the tendency to the formation of alkaline 
stools ; on the other hand, when large quantities of 
raw milk are fed there is a tendency toward the 
formation of so-called hard protein curds which may act 
as mechanical irritants to the intestine, increasing peri- 
stalsis and secretion, with a resulting increase in number 



DISTURBANCES WITH DIARRHEA. 221 

of stools with a lessened consistency. This is rarely 
seen in the normal infant, unless more than one and 
one-half ounces of raw milk are fed per pound body 
weight. It may, however, develop on lesser quantities 
in infants who have suffered from previous nutritional 
disturbances. Far more frequent are the cases brought 
about by increased acid fermentation, which causes in- 
creased- peristalsis and increased intestinal secretion with 
resulting loss of body fluids. Pathological breaking 
down of carbohydrates (sugar, flour) is the most fre- 
quent cause, and is often the primary factor, while the 
fat, in most cases, is involved only secondarily as a re- 
sult of increased peristalsis and fermentation. The 
sugars in strong solution have a hydragogue action and 
they also provide a favorable medium for bacterial 
growth. While the fats may have a mechanical effect 
and thereby act as laxatives, when fed in excessive 
amounts this is only exceptionally the manner in which 
they cause diarrhea. Much more frequently, the irrita- 
tion is due to the esters of the lower fatty acids which 
give rise to acids capable of increasing peristalsis when 
they are split by the enzymes of the digestive juices. 
This action is enhanced by an excessive carbohydrate 
fermentation. It is also true that an excess of fat has 
an unfavorable influence on the sugar tolerance. By 
the reduction or complete withdrawal of carbohydrates 
the pathological fermentation can in almost all cases be 
decreased and also the peristalsis. The different carbo- 
hydrates show different tendency to fermentation. Milk- 
sugar ferments most easily, less easily the cane-sugar, 
and least the maltose-dextrin preparations. By clini- 
cal experiments it was found that the tolerance of even 
the same intestine towards carbohydrates is not always 
the same, and that it also depends to a certain extent 
upon the quality of the fluid in which they are dissolved 
or suspended. The same amount of sugar given with 
large quantities of whey produces dyspeptic symptoms 



222 IN FA XT FEEDING. 

much more easily than the same amount of sugar ad- 
ministered in less whey or in water. From this it fol- 
lows that in pathogenesis of this group of artificially fed 
infants the whey is also of importance, the quality and 
quantity of the whey salts may become the deciding fac- 
tor in the development of diarrhea. This group of cases 
is frequently described under the title of fermentative 
diarrheas. The mechanical diarrhea due to raw protein 
curds has been described — in older infants similar cases 
may be seen when the semi-solid foods are given, more 
particularly fruits and vegetables, among the latter those 
in which the vegetables are not properly pureed. Cer- 
tain vegetables may also act as chemical causes, more 
commonly unripe fruit and green vegetables, such as 
apples, cabbage, cucumbers, etc. 

Infected foods, such as spoiled milk, may result in 
acute disturbances which may be due to the bacteria 
themselves but more commonly to the bacterial action 
on the fats and sugars with the formation of toxic bodies. 
One of the greatest disadvantages of feeding infants on 
commercially pasteurized milk, as is done in many of 
the large cities, is the fact that the non-pathogenic lactic 
acid organisms are destroyed and many of the patho- 
genic organisms remain which grow in the milk as it 
ages. Therefore, sweet milk does not necessarily mean 
good milk. The destruction of the lactic acid organisms 
prevents the souring of the milk which is of best aid in 
detecting stale milk. It is well known that milk may 
be sour and cause no symptoms. The action of such or- 
ganisms as the Bacillus lactis and Streptococcus lactis, 
by the production of lactic acid, exert an inhibitory ef- 
fect on many of the pathogenic organisms, while their 
own products are comparatively harmless. 

Subnormal food tolerance due to preceding dietetic 
errors and nutritional disturbances, is one of the most 
important predisposing factors to recurrent diarrheal 
disturbances. Infants with such a tendency must be 



DISTURBANCES WITH DIARRHEA. 223 

kept under constant observation and the earliest evidence 
of a tendency to the development of a fresh attack must 
be given proper consideration so that the causative fac- 
tor may be eliminated. These are the cases which so 
frequently pass into the stage of athrepsia and anhyd- 
remic intoxication. 

Infections. Infants suffering from parenteral infec- 
tions, such as tonsillitis, rhinitis, otitis, pneumonia and 
pyelitis, are likely to develop a diarrhea in the course 
of their infection. This is probably due to the fact that 
the infection lowers the functional capacity of the 
gastro-intestinal tract, results in lessened secretion of 
digestive juices, decreased absorption and an increased 
irritability. Usually the diarrhea is preceded by fever 
and often by vomiting. A careful study of the diet re- 
veals no error in the feeding and there is usually a dis- 
proportion between the gastro-intestinal symptoms and 
the evidences of systemic involvement, more especially 
the fever. While this type calls for a reduction in the 
diet, prolonged starvation is to be avoided in order to 
prevent lessening of the infant's immunity. There is 
another probable explanation for the development of 
diarrhea in the presence of parenteral infection, in that 
in the presence of the general debilitating influence of 
these systemic infections the intestinal mucous mem- 
brane loses some of its anti-bacterial power and thus 
allows bacteria to flourish higher in the intestine than 
they would normally. 

Enteral infections will be discussed in detail in a later 
chapter. (Page 284.) 

Extremes of temperature, heat of summer and cold of 
winter, with resulting systemic depression, lead to diges- 
tive disturbances. It is a well-established fact that in- 
fants are greatly depressed by overheating of the body 
due to high external temperatures. The condition is 
readily aggravated by the wearing of excessive clothing 
during heat of summer; therefore, infants should be 



224 INFANT FEEDING. 

dressed to meet the needs of the temperature of a given 
time in the day. It is wise to allow the mother to use 
her judgment as to over- or underdressing, after the 
possible effect on the child of overheating has been 
properly explained. Most infants will suffer more from 
heat in the presence of an excessive humidity and this 
should also be given proper consideration in considering 
the clothes for the infant's use. It is also true that less 
food is required during the summer months to nourish 
an infant, while at the same time more water is needed. 
These facts should be remembered and be taken advan- 
tage of as prophylactic and therapeutic measures. Un- 
fortunately, this is not heeded in many cases, because 
the child is more thirsty, and, its food being liquid, 
quenches its thirst and is therefore given in excessive 
amounts; and secondly, because the cry and discomfort 
due to the same overfeeding and heat are interpreted as 
hunger. It should, therefore, be the duty of the phy- 
sician to warn against excessive feeding during the hot 
summer months ; that these latter are factors is evidenced 
by the fact of their prevalence among the poor and 
ignorant. 

Certain constitutional anomalies lead to lessened food 
tolerance. Among these is an idiosyncrasy to coixfs milk 
which is fortunately one of the rare disturbances. Usu- 
ally the first feeding with cow's milk will result in acute 
vomiting, diarrhea and erythematous rash and not in- 
frequently low grade fever. Withdrawal of cow's milk 
from the diet usually results in disappearance of the 
symptoms. Infants suffering from the exudative di- 
athesis and infantile eczemas often show a tendency 
toward the development of diarrhea in the presence of 
minor dietetic errors, more especially so in the presence 
of parenteral infections, at which time there is a ten- 
dency on the part of the eczema to disappear which goes 
hand-in-hand with the increased irritability on the part 
of the gastro-intestinal tract. Some infants, from birth, 



DISTURBANCES WITH DIARRHEA. 225 

show a tendency to develop marked nervous manifesta- 
tions upon slight external irritation. It is this class of 
cases which early develop pylorospasms and repeated 
vomiting. They are also subject to attacks of gastro- 
intestinal colic and they are often hypersensitive to light 
and sound. They form bad habits which lead to im- 
proper feeding due to misinterpretation of their cry. 
Intestinal disturbances are common complications. Even 
in the ordinary infant nervous exhaustion and excitement 
lead to impaired gastro-intestinal functioning and must 
be avoided. 

Chronic diseases of the heart and kidneys, more espe- 
cially when associated with decompensation, are fre- 
quently accompanied by diarrhea. These are in large 
part due to interference with elimination. Chronic dis- 
turbances of the liver and pancreas may be underlying 
factors in the development of diarrhea. 

Repeated and excessive administration of cathartics 
is one of the most common causes of diarrhea. It has 
been conclusively shown that the stools become abnor- 
mal in the presence of repeated cathartics. Calomel, 
when given in divided doses of one-tenth grain per dose, 
with a total administration of one grain daily for three 
consecutive days, will cause the presence of mucus and 
blood in practically every case ; one dram of magnesium 
sulphate, given daily for three days, will cause the same 
result; castor oil, while less irritating, when repeated, 
will cause a similar reaction. It is self-evident that re- 
peated catharsis is to be avoided. 

Symptoms. Acute intestinal indigestion is charac- 
terized clinically by acute gastro-intestinal symptoms, 
the most marked of which are the stools, which are in- 
creased in number, and of an abnormal quality. In the 
milder types the organism does not show signs of any 
deep-seated general changes and weight loss is moderate. 
Quite commonly the gastric disturbances are associated 
with diarrhea, the causative influence being something 

15 



226 INFANT FEEDING. 

ingested which irritates the stomach and then passes into 
the bowels, or both may be affected simultaneously in 
the presence of systemic involvement. Temperature is 
moderately increased, and repair is rapid with the with- 
drawal of improper food. The presence of high or con- 
tinued fever should lead to a careful search for a sys- 
temic involvement outside of the gastro-intestinal tract 
and for evidence of an indefinite infection. 

Severe general symptoms are usually absent in the 
early stages. The mind is clear. The heart action is 
not rapid. Respirations are not greatly increased. The 
baby is restless and fretful, cries a great deal of the time, 
sleeps brokenly, and sucks its hands and other objects 
as if hungry. The face soon becomes drawn, and the 
tissues more or less flabby through loss of body fluids. 
The skin shows little change. The urine is diminished 
in amount, the quantity being dependent upon the amount 
ingested, and the extent of loss of fluids through vomit- 
ing and diarrhea and through loss by way of the skin. 
In the milder types there are no other abnormal urinary 
findings. 

Weight. The weight loss varies directly with the loss 
of body fluids through the increased secretion, intestinal 
peristalsis and consequent diarrhea. 

Gastro-intestinal Symptoms. The appetite is poor. 
The mucous membrane of the mouth is red, and may 
be the seat of thrush (due to decreased immunity). 
Vomiting may be present, and usually occurs long after 
feeding, more often preceding diarrhea by from twelve 
to twenty-four hours. Volatile fatty acids may be de- 
tected in the stomach content by their odor. The abdo- 
men is distended, and peristalsis increased, and is visible 
or can be heard by auscultation. Restlessness is marked 
and is usually relieved temporarily upon passage of 
flatus. 

Stools. The clinical diagnosis is usually made from 
the stools. They are increased in frequency, and they 



DISTURBANCES WITH DIARRHEA. 227 

also differ from the normal. They are thinner, con- 
tain more mucus, and are either watery or hashy. There 
is an abnormal odor, either that of decomposition or 
that of acid fermentation. The reaction is variable, 
mostly acid. The color of the stool is often green, this 
being due to transformation of bilirubin to biliverdin by 
oxidizing ferments. It is then passed without being re- 
duced to urobilin, the normal transformation in the large 
intestine. 

The increased peristalsis results in impairment of ab- 
sorption, which may easily be determined by metabolic 
experiments, and also estimated by macroscopic, micro- 
scopic, and chemical examination of the stools. 

Fatty acids and calcium and magnesium soaps appear 
in the stools in the shape of white or yellowish lumps, 
and, by addition of strong acids and slight warming, 
fatty acid needles may be crystallized from them. 

Part of the fat is present in the form of smaller or 
larger neutral fat globules. 

The acid reaction is in the greater part due to the 
fermentation of sugar which has escaped absorption in 
the small intestine and which is supplied by bacteria in 
the colon. When considerable amounts of sugar are 
fermented in this way the stools become foamy. The 
irritation of the colon also leads to excessive secretion 
of mucus and later blood may appear. The appearance 
of blood varies with the places of hemorrhage and the 
time which it is in contact with the intestinal contents. 
The presence of pus should lead to the suspicion that 
ulceration of the intestinal mucosa has taken place. The 
latter is rarely present in the simple types of intestinal 
indigestion and should be considered as a grave com- 
plication. 

If flours are in excess, the stools are frequently paste- 
like and foamy. I ly iodine solutions the unchanged 
starches are stained blue, and the erythrodextrin is stained 
red. 



228 INFANT FEEDING. 

Recent research has demonstrated the frequency with 
which casein is found in the stools. The yellowish 
lumps, the so-called milk-curds, in the hashy stools, seen 
even in feeding with boiled milk, have erroneously been 
regarded as casein curds. Today we know positively that 
these so-called "casein curds" are composed chiefly of 
fatty acid salts and bacteria. In feeding with raw milk 
large, tough, bean-like casein curds may pass through 
the intestine without being digested. Even in the pres- 
ence of true casein curds, however, one must not con- 
clude that they are the primary factors in the pathogene- 
sis of this nutritional disturbance unless we are certain 
that an excess of raw milk has been fed. 

Varieties. First, the acute, which begins with a defi- 
nite acute onset, usually in infants who have been previ- 
ously well, and second, the chronic, which begins less 
acutely, or follows acute attacks, and which recurs even 
in the presence of a carefully regulated diet. It soon 
becomes evident that in the latter cases there is a definite 
lessening of the food tolerance. 

Diagnosis. The diagnosis can be made only by care- 
ful consideration of the feeding history and the clinical 
and functional symptoms. 

It is first necessary to differentiate those unassociated 
with infection from the milder forms following enteral 
and parenteral infections. One must remember that the 
infections, especially in young infants, are frequently 
associated with a secondary nutritional disturbance, and 
vice versa, that secondary infections commonly follow 
in the wake of nutritional disturbances. An infection 
should be suspected when the temperature remains high 
after the withdrawal or reduction of the food (especially 
of the carbohydrates ) , and when albumin and hyaline 
casts appear in the urine, and the mucus continues in 
excess in the stools, presenting the picture of a second- 
ary enterocolitis after the correction of dietetic errors. 
If infections are not recognized, there is a great danger 



DISTURBANCES WITH DIARRHEA. 229 

of continuing the starvation diet too long, and thereby 
reducing the vitality of the infant to the stage of athrep- 
sia. It is also of importance to note whether it is a 
primary* or an acute exacerbation in the course of an 
athrepsia, as on this differentiation to a great extent de- 
pends the prognosis and the therapy. Here, again, a 
careful history is of vast importance, and one should 
carefully note the presence of repeated attacks, with re- 
curring fluctuations in weight, the occurrence of previ- 
ous infection, both enteral and parenteral, as all of these 
indicate a tendency to malnutrition. 

Prognosis. In' infants previously healthy and with 
a proper dietetic treatment, the prognosis is good. Re- 
peated attacks should always be seriously considered. 
Intestinal indigestion in very young infants is always 
more serious than in the older and better developed ones. 
The determination of the stage of nutritional disturbance 
gives us no indication as to whether we have a light or 
serious disturbance. What the physician needs to learn 
is that the condition of the infant should not be esti- 
mated only by its weight and the character of the stools, 
but also on the basis of its tonus and turgor, the color 
of the skin and the state of the sensorium. We must 
necessarily consider the nature and the quantity of the 
stools, since the diagnosis of this condition is in the first 
place determined by the presence of diarrhea. The de- 
gree of stomach involvement, however, must be based 
on the condition of the infant in whom it occurs. As 
a rule, most cases, if promptly treated, belong to the 
class of milder nutritional disturbances. However, these 
infants are always in danger of developing a general 
serious disturbance, more especially the very young and 
those who have suffered from repeated attacks as the 
result of long-continued starvation and excessive loss of 
water and body fluids, both of which tend to a destruc- 
tion of the tissues. For practical purposes it is well to 
classify these infants, as to prognosis, into three types: 



230 INFANT FEEDING. 

first, those who have been previously normal ; second, 
those suffering from mild degrees of malnutrition, and 
third, those seriously emaciated either through consti- 
tutional defects or repeated nutritional disturbances. 
Among the latter group those that suffer from repeated 
diarrheal attacks are especially likely to succumb. A 
very acute nutritional disturbance prepares the field for 
the subsequent ones and decreases the tolerance for the 
various food mixtures. All diarrheal attacks have a ten- 
dency to result in the stage of malnutrition, and the se- 
verer ones in marasmus, which latter condition will be 
described in the chapter on Athrepsia. 

The loss of water by way of the stools and skin and 
the diminished retention as a result of vomiting tend to 
a desiccation of the body tissues, which in the severe 
types leads to the characteristic clinical picture which 
will be described in the chapter on Anhydremic Intoxi- 
cation. 

Treatment. Prophylactic Measures. During the heat 
of summer and where there is any uncertainty as to the 
quality of the milk it should be boiled. It should also 
be remembered that less food and more water are re- 
quired during the hot months. Over-clothing in sum- 
mer and insufficient protection in winter predispose to 
diarrheal conditions. In the presence of diarrhea high 
carbohydrate feeding should be discontinued. 

Human Milk. The best treatment of all forms of 
intestinal indigestion consists of feeding human milk. The 
younger the infant, the more the indication for human 
milk. This is especially true of infants under two months 
of age. In severe cases it may be necessary to place the 
infant on a starvation diet for six to twelve hours, and 
then administer the breast milk in restricted amounts. 

Artificial Feeding. In artificial feeding the treatment 
of acute intestinal indigestion is somewhat different from 
the treatment of the chronic variety. 



DISTURBANCES WITH DIARRHEA. 231 

Acute Forms. In the acute form, where the child was 
previously well and its tolerance good, the simple un- 
loading of the intestine may allow it to resume its nor- 
mal function. The following treatment is recommended : 

1. Starvation or Hunger Diet. Short (six to twelve 
hours, rarely longer) starvation, only liquids being ad- 
ministered, tea with saccharin being the best (saccharin, 
1 grain (0.065 Gm.) to 1 quart (1000 mils)). They 
should be given freely, up to amounts of the total fluids 
needed. This permits the stomach and the intestines to 
empty themselves, and to assume their normal functions. 
Laxatives are usually not indicated. If temporary 
starvation is inaugurated, the intestinal tract soon emp- 
ties itself of its irritating contents. 

Upon suspicion that spoiled or otherwise improper 
food has been fed, a single dose of cathartic may be in- 
dicated. Of these the least harmful are castor oil and 
milk of magnesia. The repeated administration of laxa- 
tive drugs is absolutely contraindicated. This applies 
more especially to calomel. 

2. Indifferent Diet. During the second day in young 
infants, one-third whole or skim milk (boiled five min- 
utes) plus two-thirds water or thin oatmeal gruel, with- 
out sugar, may be fed, such a diet being low in food 
value and salts. The total daily quantity of the milk 
mixture on the second day should not exceed six to 
eighteen ounces (180 to 540 mils), divided into six feed- 
ings of one to three ounces each. To this, twenty to 
twenty-five ounces of tea, plus saccharin, may be added, 
making a total of at least one quart of fluid for the day. 
Even better results will be obtained by the use of lactic 
acid milk, at first fat-free and later whole. These can 
be prepared by inoculating boiled milk with a pure live 
culture of one of the lactic acid-producing organisms 
which can be obtained on the market. The preparation 
of the lactic acid milk can be begun with the institution 
of the starvation period, as it must be inoculated from 



232 INFANT FEEDING. 

twelve to twenty-four hours, after which it must be kept 
on ice. The lactic acid milk can be feci in somewhat 
larger amounts than sweet milk. This is probably due 
to the fact that the lactic acid bacillus has a retarding 
action on the growth of many of the other organisms 
which may be present in the intestinal tract. Such an 
action is especially valuable when it affects the growth 
of the abnormal flora in the upper intestinal tract, know- 
ing that the irritation, more particularly of the small 
intestine, interferes with the process of digestion and 
absorption which are so necessary to the relief of this 
class of infants. In young infants and in the severer 
cases lactic acid milk prepared from skim milk is to be 
recommended over that made from whole milk during 
the first stage of the treatment. 

Further treatment depends on the reaction to the 
above. Upon this treatment the general condition im- 
proves, also the disposition, etc., and the weight loss 
ceases in two or three days. When this is not the case, 
infection should be suspected. 

3. Sustaining Diet. Gradually, and as rapidly as pos- 
sible, the food should be increased, the increase to be 
made at least every other day, in order to limit the under- 
feeding to a minimum. By the third day or before, the 
quantity of food should be increased, the quality may 
be left unchanged, giving water or tea to the necessary 
quantity of fluids between the feedings. Weight increase 
should not be expected because of the low sugar content 
and low caloric value of the diet, but a decrease in weight 
should always be considered serious. The stools are at 
first small and contain mucus, later less frequent, and 
often on milk mixtures without sugar fat-soap stools 
soon appear, which is a good indication. 

4. Ordinary Diet. In mild cases, the ordinary milk 
mixtures proper for the given infant may usually be re- 
sumed by the end of a week. In more severe cases, 
return to a full diet should be slower. In these mix- 



DISTURBANCES WITH DIARRHEA. 233 

tures, the carbohydrates should be started by adding one 
gram and gradually increased to four or five grams for 
each pound of body weight, only exceptionally, however, 
should the total addition of sugar exceed forty-five 
grams (1% ounces). The carbohydrates most suitable 
for this purpose are the maltose-dextrin compounds, es- 
pecially those with a high dextrin content and no potas- 
sium carbonate. Corn syrup is also valuable, being in part 
at least absorbed in the upper intestinal tract and thereby 
causing less intestinal irritation. It may be added in 
amounts of 15 to 60 mils to the day's total food. In older 
infants cereals, in the form of flour ball, barley flour, 
farina, zweibach, can often be added to advantage, as 
well as clear broths. At first there is a rapid increase in 
weight, later on a slower one. 

Avoid underfeeding too long, even if the stools look 
bad, if the temperature and weight curves improve, be- 
cause of the danger of athrepsia. It should be borne 
in mind, therefore, that it is undesirable to underfeed 
for a long period, and more especially dangerous to in- 
augurate starvation repeatedly, or to keep an infant for 
days on a starvation diet, : such as cereal waters or very 
weak milk mixtures. It is also necessary to know and 
recognize the stools of an underfed infant (hunger 
stool). This is greenish-brown in color, composed chiefly 
of mucus, and small in amount, and sometimes frequent. 
They should not be mistaken for the curd-containing, 
frequent stools of intestinal indigestion, as the former 
is an indication for the resumption of food, while the 
latter indicates starvation. Fats can be added in place 
of sugars, but this should be done with care. Cod-liver 
oil has given us the best results. It should be given in 
small quantities at first, beginning with one mil twice 
daily, and increased to four mils per dose. 

In some infants the above-described treatment is un- 
successful. In one group of these cases the loss of 
weight is not favorably influenced, while the stools im- 



234 INFANT FEEDING. 

prove; and in a second group the loss continues with 
continued diarrhea. In these cases there is either infec- 
tion or they are cases of grave nutritional disturbances 
on transition to athrepsia. It would be a very great 
mistake to continue starvation longer, with the idea that 
by giving the digestive tract longer rest, it may still re- 
cover. This may kill the child. In these cases treat- 
ment as recommended for athrepsia or infection must 
be instituted. Therefore, it is advisable to use routine 
treatment as described above, and, if not successful, the 
underfeeding should not be continued under any cir- 
cumstances, but the treatment for athrepsia (described 
later) or infection (see Infections) should at once be 
instituted, if human milk is not obtainable. 

It is in these cases that Finkelstein's albumin (pro- 
tein) milk is indicated. (See Appendix, for preparation.) 
The albumin milk may be administered undiluted in the 
same quantities recommended for the lactic acid milk 
and increased three ounces (ninety mils) daily until 
three ounces per pound (180 mils per kilogram) are 
administered. 

The value of feeding with the lactic acid milk and 
albumin milk is due to the presence of the lactic acid 
bacillus and its product, lactic acid, and their high pro- 
tein and low sugar content and their small curd. The 
latter also has the added advantage of having a low salt 
content. After the stools become firm, sugar should be 
added to both the lactic acid milk and the albumin milk, 
beginning with one-half to 1 gram and gradually increas- 
ing to four grams for each pound of body weight, with 
a maximum addition of forty-five to sixty grams. Car- 
bohydrate starvation, more especially in the presence of 
high fever, is an added danger, and addition of sugar 
to the diet may be imperative, even in the presence of 
soft stools. Maltose-dextrin compounds which do not 
contain potassium carbonate are the best for this pur- 
pose. We have found that 1 per cent, of flour (flour ball) 



DISTURBANCES WITH DIARRHEA. 235 

may be added to the albumin milk, thereby raising its 
caloric value without decreasing its efficacy, at the first 
feeding. After three or four weeks, in both mixtures, 
it is usually safe to replace them in part or entirely by 
a suitable milk formula for a child of a given age. It 
is usually wise to reduce the sugar in the formula dur- 
ing the first days of the new feeding. 

When it is not practical to prepare the lactic acid milk 
or the albumin milk in the home, the albumin milk may 
be used in the dry form, in which it can be obtained on 
the market (See Appendix). 

The protein content of the sweet milk mixtures can 
also be increased when desired by the addition of one 
of the casein products which are now to be obtained in 
quantities varying from 1 to 3 per cent, of the milk con- 
tent in the mixture (See Appendix). 

For the treatment of the severe types with toxic symp- 
toms, see Anhydremia. The treatment of enteral infec- 
tions is discussed in the chapter on Infection and 
Nutrition. 

Chronic Cases. In treatment of chronic forms there 
is no indication for underfeeding. Since here there is 
no transitory weakness, but a chronic weakness of toler- 
ance, the additional trauma of starvation would have an 
unfavorable influence. Fats must be reduced. Skim 
milk, buttermilk and albumin milk are often better taken 
than whole milk mixtures. Carbohydrates are to be re- 
duced to the infant's minimal needs (two to four grains 
per pound body weight), and the less easily assimilable 
carbohydrates may be replaced by those that are more 
easily assimilated (maltose-dextrin mixtures or corn 
syrup). If this does not improve the stools, then nurs- 
ing on the breast is necessary. The quantities of foods 
taken should be carefully measured and recorded to 
prevent prolonged underfeeding with the hope that when 
the child becomes older the tolerance will become physio- 



236 INFANT FEEDING. 

logically increased, and the condition thereby undergo 
spontaneous healing. 

Medicinal Treatment. This is unnecessary in most 
cases. When the starvation period shows no tendency 
to decrease the number of stools and where there is con- 
siderable pain and flatulence, it may be necessary to 
administer small doses of opium and atropin. Paregoric 
is the safest form for administration of opium. Depend- 
ing upon the age, it may be administered in doses from 
two to ten minims, to be repeated as indicated by the 
effect on the gastro-intestinal tract and the general symp- 
toms. If atropin is used, the doses must be carefully 
graduated, in young infants, and should range from 
M.500 to /ioo OI a grain. Epinephrin in %ooo solution, 
1 to 5 minims by mouth, may be indicated where there 
is marked atony on the part of the intestinal tract. A 
pure culture of lactic acid, when feeding sweet milk mix- 
tures, is often of value. It may be administered in the 
form of powder or liquid culture. 

Marriott has recently recommended the administra- 
tion of argyrol. He advises 6 grain doses prescribing it 
in a 10 per cent, solution, of which 4 mils are given in 
each feeding. It can be continued for from two days to 
two weeks. He believes that this has an inhibitive action 
on the growth of the bacterial flora in the upper intes- 
tinal tract. The stools are stained a deep brown when 
such medication is used. 

For the treatment of irritative conditions which per- 
sist even after the intestinal indigestion proper has dis- 
appeared (loose stools in presence of gain in weight), 
astringents are of use. Tannigen or tannalbin, 1 to 5 
grains (0.065 to 0.325 Gm.) four to five times daily, 
will answer, or calcium lactate in doses of 10 to 15 
grains (0.65 to 1 Gm.) may be prescribed in a 10 per 
cent, solution to be added to each milk feeding. 



CHAPTER V. 
ATHREPSIA (DECOMPOSITION). 

Synonyms: Malnutrition, marasmus, infantile atrophy, 
pedatrophy. 

The term athrepsia was first used by Parrott in 1877 
to describe secondary nutritional disturbance with result- 
ing severe malnutrition. The same symptom-complex 
is described as the "stage of decomposition" by Finkel- 




Fig. 9. — Infant with athrepsia (decomposition). 

stein. The milder types of athrepsia are, in the Ameri- 
can literature, described as cases of malnutrition and 
the more extreme grades as marasmus. The cases will 
range in severity from those which simply show an in- 
sufficient gain or a stationary weight with few systemic 
changes, to the most extreme types, which will be de- 
scribed more in detail. 

The clinical picture may be viewed as the end-result 
of repeated nutritional disturbances or constitutional 
factors. The result of such prolonged or repeated under- 
nourishment must necessarily be malnutrition, of a more 
or less marked degree, depending upon the disproportion 
between the food utilized and the needs of the body for 
energy and growth. 

The past history of the patient is of the utmost im- 
portance, and a careful search reveals improper diets, 

(237) 



238 INFANT FEEDING. 

with resulting disturbance of nutrition, or a nutritional 
disturbance following enteral or parenteral infections, 
each leaving in its wake evidence of impaired nutrition, 
until after weeks or months we have reached the stage 
of deep-seated tissue starvation. Most frequently athrep- 
sia results from repeated injuries and therefore is classed 
as a subacute or chronic condition. It may, however, 
develop more rapidly in the presence of an acute diar- 
rheal disturbance. The chronic infections, such as 
syphilis and tuberculosis, pyelitis and otitis, may also re- 
sult in a similar picture, but must be differentiated to 
clear the classification for therapeutic purposes. It is 
very commonly seen in infants suffering from congeni- 
tal weakness or disease, such as prematurely born infants 
and those suffering from congenital heart, pulmonary, 
gastro-intestinal and cerebral lesions. 

During this stage it becomes increasingly difficult for 
the infant to assimilate a sustaining diet, with resulting 
extreme loss of weight, and of resistance of the organ- 
ism to infections and other injurious external influences 
(heat, cold), this general weakening of the vitality of 
the infant being due to perverted metabolism, consisting 
of breaking down of the body substance, and change in 
the composition of the cells (abnormal katabolism), and 
of deficient and improper assimilation of the food (ab- 
normal anabolism ) . 

Etiology. The milder types of malnutrition due to 
dietetic errors are usually direct forerunners of the stage 
of athrepsia. All the factors which lead to diarrhea dis- 
turbances, anhydremia and intoxication may also be 
causative factors of athrepsia. At what moment this 
change takes place we have no means of telling, but we 
know that deep-seated organic changes are necessary to 
its development ; these changes which produce such an 
intolerance toward nourishment may have developed 
previously to the preceding illness, or during its course. 
Premature infants are especially predisposed, also young 



ATHREPSIA. 239 

infants with previous dietetic errors and diarrheal at- 
tacks, also those fed on a one-sided diet, excessive in 
carbohydrates, especially cereal waters and gruels, as 
seen in too long continued "starvation diet." Especially 
to the very young does "the statement as to cereal waters 
and gruels apply. All of the preceding reduce the toler- 
ance toward assimilation of a full and normal diet. The 
tendency to athrepsia, and therefore to the narrowing 
of the nutritional sphere increases with each diarrheal 
attack. Czerny's internal hunger, or, as he commonly 
calls it, "cell hunger," is the cause of athrepsia. The 
above term is used in contradistinction to hunger as 
usually thought of, which is due to a lack of food to 
appease the appetite. 

While a considerable number of the cases of athrep- 
sia are due primarily to underfeeding, such as by nurs- 
ing on dry breasts or in artificial feeding by the giving 
of food mixtures which are insufficient to meet the in- 
fant's needs, either because of a too small quantity or 
prolonged feeding of an improperly balanced diet which 
is too low in some of the necessary elements, the ma- 
jority of the cases follow in the wake of the acute 
nutritional upsets which may or may not be based upon 
previous errors in diagnosis. Following such digestive 
disturbances the time is soon reached when even in the 
presence of a feeding of sufficient calories which are 
properly distributed, the functions have become so im- 
paired that the products of metabolism cannot be utilized 
by the body tissues. 

Pathogenesis. In the American literature the term 
marasmus is quite generally used to describe the clinical 
picture as presented by the severe types. It was assumed 
that the destructive changes in the intestinal glands fol- 
lowing chronic inflammation, with a secondary impair- 
ment of the functions of absorption and excretion, were 
the underlying pathological conditions, which resulted in 
an inanition, ft is, however, rarely possible to demon- 



240 INFANT FEEDING. 

strate pathologic involvement of the secretory glands, 
even in the severe types. Marriott has suggested that 
due to the fact that there is an atrophied and poorly 
circulating blood stream, it must necessarily result in 
inefficient functioning of the digestive glands and a di- 
minished absorption from the intestinal tract, both of 
which would necessarily be important factors in the 
development of the clinical picture. 

Every organ of the body suffers more or less from 
the effects of an insufficient food supply. The blood 
volume is markedly diminished as well as the volume 
flow, so that the amount of blood passing through a 
given part of the body in a unit of time is much dimin- 
ished under the normal. Marriott and Perkins 1 found 
that in normal infants under one year the average blood 
volume was 9.1 per cent, of the body weight. In a 
group of eleven athreptic infants the average was 8 per 
cent, of the body weight, the most extreme variation 
being 4.8 per cent. It should be remembered in con- 
sidering the figures for athreptic infants that these in- 
fants were greatly emaciated and under weight and that, 
therefore, their blood volume was reduced to a greater 
extent than the percentage figures would at first lead 
one to believe, showing that there had been a very con- 
siderable destruction of the blood coincident with the 
loss of other body tissues. Along with these figures in 
blood volume they also found the volume flow to be 
decreased often to less than one-fifth and occasionally 
to less than one-tenth of the normal. During conva- 
lescence the volume flow increases with the treatment. 
They also found a concentration of the protein in the 
serum of these infants, also a diminution in the red 
blood cells and hemoglobin. This may be further ag- 
gravated by myocardial weakness as the heart muscle 
undergoes the same destructive changes as do the tis- 



1 Marriott, W. McKim: Amer. Jour. Dis. of Children, xx, 
461, 1920. 



ATHREPSIA. 241 

sues in general. The blood pressure sometimes falls 
below normal, due to the fact that in addition to the 
other pathological conditions in the circulatory system 
there is an absence of increased viscosity of the blood. 
The decreased blood volume leads to a constriction of 
the arterioles and this leads to a piling up of the cor- 
puscles in the capillary blood. The adipose tissue dis- 
appears ana there is an autophagia of the protein ele- 
ments and a chronic loss of water and of mineral sub- 
stances. The earlier stage may be described as one of 
the hypo-athrepsia and the late severe types as that of 
athrepsia. In the breast-fed the severe types are rarely 
seen unless preceded by intercurrent disease. In the 
artificially fed the stage of hypo-athrepsia may progress 
to athrepsia even after the primary digestive disturbances 
have subsided and in the presence of insufficient or im- 
proper diet. This condition is especially prone to de- 
velop in the environment of institutions and asylums 
unless the nursing care includes a sufficient amount of 
"mothering" and massaging of the infants. The super- 
vision of the feeding of infants is of extreme import- 
ance, so that they may be sure of obtaining their diet 
in its entirety and while it is warm. 

The great and sudden fluctuations in weight, as seen 
in this condition, must in the first place be due to loss 
of water and salts, while the disintegration of the body 
substance, other than the blood, including the cells, fur- 
nishes only a smaller proportion of the loss of weight 
which occurs. 

Further, the abnormal splitting of sugar and fats con- 
tained in the food produces excessive amounts of acids 
in the intestines, which results in the loss of alkali salts, 
first, through neutralization of the acids formed in the 
intestinal tract from the food, and secondly, through salt 
losses due to excessive intestinal secretion, due to irri- 
tation of the bowel. As a result of such enteral loss 
of salts an increased NH-excretion takes place, which 

16 



242 INFANT FEEDING. 

is evidenced clinically by increase of ammonia in the 
urine. 

To cover these losses, salts deposited in the tissues 
are in part withdrawn, and finally the cells themselves 
are destroyed through being deprived of their salt con- 
tent (mineral hunger). It should be remembered that 
an abnormal fat metabolism is frequently the essential 
factor in the etiology of this condition, due to an over- 
stepping of the fat tolerance. And further, that fer- 
mentative changes in the carbohydrates produce increased 
acidity of the contents of the intestinal canal, and so 
enhance the action of fats. Both of these may be causa- 
tive factors in the development of diarrhea. While there 
is usually an excess of protein loss over protein assimi- 
lation, the tolerance for proteins is usually less affected. 
Because of the loss of nitrogenous substances, due to a 
relative excess in excretion of NH, proteins must be 
utilized in the diet to counteract these losses. 

There is no increase in the osmotic pressure of the 
blood and hence no diminution in the amount of urine 
secreted and no accumulation of the urinary waste prod- 
ucts of the body. Such acidosis as may occur is to be 
ascribed to causes other than retention of the acid prod- 
ucts by the kidney. The acidosis is probably in part due 
to the diminished volume flow of the blood through the 
tissues and to a lesser extent to the production of ace- 
tone bodies, the result of partial starvation. Acidosis 
is, however, by no means a prominent feature of this 
condition and rarely calls for alkali therapy. 

Increased peristalsis in diarrheal conditions results in 
further inanition, due to the passing of undigested food 
through the intestinal tract. All of this results in de- 
creased assimilation of food necessitating the burning 
of the infant's own body for fuel. The stored carbo- 
hydrates (glycogen) and fat are first used and later also 
the body protein is consumed. When this latter stage 



ATHREPSIA. 243 

is reached the maintenance of life for any considerable 
time is impossible. 

In these infants in the presence of impaired function 
on the part of the digestive tract it is quite possible that 
there may be an invasion of the upper intestinal tract 
by a bacterial flora which, under normal conditions, does 
not thrive in this region. This may act in two ways, 
by interference with the normal processes of digestion 
and absorption in the region involved, and by the setting 
up of inflammatory processes which may result in the 
involvement of the entire tract with the development of 
diarrhea. 

Marriott 1 believes that the comparative buffer value 
of the food which the infant is receiving may be a factor 
in the development of malnutrition in some infants. By 
buffer value is meant the capacity to unite relatively large 
amounts of acid or alkali without a change in chemical 
reaction. If the same amount of hydrochloric acid is 
added to equal volumes of human milk and cow's milk 
it is found that the acidity of the human milk, expressed 
in terms of hydrogen ion concentration, is far greater. 
When milk enters the stomach of a normal breast-fed 
infant gastric juice is secreted in such amounts that the 
stomach contents ultimately reach a certain degree of 
acidity. This acidity, expressed in terms of H-ion con- 
centration, averages about 1X10 — 5 , which is the opti- 
mum concentration for rennin action and is sufficient 
to markedly inhibit bacterial growth (Hahn 2 ). Sup- 
pose, however, cow's milk, instead of breast milk, is fed : 
If the same amount of gastric juice is secreted, it is 
entirely insufficient to render the stomach contents acid 
to anywhere near the same optimum degree. To bring 
cow's milk to the optimum acidity of 1X10 — 5 , at least 
three times as much hydrochloric acid is required as in 



1 Marriott, W. McKim: Amer. Jour. Dis. of Children, xx, 
461, 1920. 
-'Hahn: Am. Jour. Dis. of Children, vii, 305, 1914. 



244 INFANT FEEDING. 

the case of human milk. ( This may readily be demon- 
strated by titrating breast milk and cow's milk with 
diluted hydrochloric acid, using as an indicator neutral 
red which changes color at a hydrogen ion concentration 
of about IX 10— 5 .) 

It is interesting to note that those foods which have 
been found empirically to be the best tolerated by athrep- 
tic infants are those which have a low buffer value or 
in which the buffer is already partly neutralized by acid. 
Breast milk, well diluted cow's milk with added carbo- 
hydrate, lactic acid milk and protein milk are examples. 

Symptoms. The cardinal symptoms of athrepsia as 
concern nutrition are the inability to utilize food and 
the negative nitrogen and mineral salt balance. The 
clinical picture presented is that of a wasted infant, 
which may be of any degree of severity. It is often 
impossible to interpret the beginning of this severe form 
of nutritional disturbance. As a rule there is a history 
of repeated minor disturbances with a gradual impair- 
ment of metabolism. In other cases it may develop more 
rapidly and this is especially true in the presence of 
diarrheal attacks. Characteristic of the severer types 
is the development of diarrhea upon increased feeding 
and continued weight loss when the diet is insufficient 
to meet the infant's needs. Often it is preceded by an 
acute parenteral infection or the lighting up of a chronic 
infection, such as otitis, pyelitis, or bronchitis. The ad- 
vanced cases present the following clinical picture : 

1. Lack of ability to assimilate food is pathognomonic 
of this condition. The paradoxical reaction to food, 
mentioned in the two preceding stages of nutritional dis- 
turbances, becomes here a striking and serious phe- 
nomenon. Starvation or the institution of the hunger 
day as a therapeutic measure in these infants not infre- 
quently results in an inanition which is fatal to the in- 
fant. Again, too rapid increases in the diet are equally 
serious, and not infrequently precipitate alarming and 



ATHREPSIA. 



245 



_L . _;.h / h 






i<* \ \ \ ** 


s _L .1. jl *' -.** 






iJi r L..s r ^ z " _._ 


■^J. t :__,.< <* 


-t + 




I r I ;^ *< __._ r 


s * ^ v t * 


i - 




Q _* J , s ____.^ 


gild J* I /___/___t« 


I ^ - 




;I|i r T \l...** 


'flji 1 /.A... a 






mi r :... T \__\__J 


TJ, L_____.< a 






3 ^r* t \ , £* 


„ ^ ........... _..__.^ 


1 . 






1 *m \ \ i * 


,- 




J* " _■— . '..„1_... -V-+: 


i ! j / /« 


- 


3 0< 
etu2 


5 < rt( uar. s -o; iiijs-<oj ^ « 


1" ; *o ' /I* 


1 ! 




q r ' • ,'Y t* 


R • * i A I« 


6x 

ex 






& c L^"?" 2 go, s "H 1 "-' / <'V««'»£ 


Ex 
Ex<i 




Q O : , ^ & -1 B ari i y "3 


j T: 7 3« 


c 6xi 

5 g; 




t;;:;;:;;;;:u:;:z;;;;;;;> ____ 


- t' -> ----- 


S |XV 






_ ^ jf"""^;; *« " . 


1 lx« 




J i %—1-t- ** 




T 


O 
| 


.3! 1 ft / « 


§ * J / 1 ° \ *i 


c 10 


ooc 


I <t rr"V<' *-■ 


g e o Houvaiaan skouhas 5 | : = : : : 




ill 

r .ii 


?j £ : 8 s 5 I H s = ! ■ • • ■ : " ° s s s a 


>-U « .O <J o « «& "» S I)||mc,po«a 

I a a i a a a 5 « aooj 

<0 3) <0 h- ^ t*- 


s? PA jljl 



246 INFANT FEEDING. 

fatal symptoms. When the condition has progressed to 
this degree, human milk alone offers hope of recovery. 

2. Loss in weight is the second cardinal symptom of 
athrepsia, due, as the name of this condition suggests, 
to disintegration of the body substance. This may be 
slight in the beginning, and in the light cases ; in the 
later stages and in severer cases, however, it is often 
sudden and rapid, and may reach daily losses from 1 
to 3 ounces (30 to 100 Gm.), resulting eventually in a 
picture of marasmus. The baby becomes thin, emaci- 
ated, wrinkled, with prominent ribs, covered with tightly 
drawn skin, and with intercostal spaces deeply marked 
(skeleton-like). The tissues are soft and flabby, the 
muscles either relaxed or hypertonic, the abdomen pro- 
tuberant, usually distended ; the color, pale first, later 
changing to characteristic grayish-white, with more or 
less cyanotic lips, fingers and toes. The mouth appears 
large, the cheeks sunken, and the facial expression anxi- 
ous and serious. These characteristics give to the in- 
fant the appearance of a wrinkled, old man. As has 
been previously stated, in the earlier stages, these babies 
are irritable and apparently in constant distress, cry a 
great deal, and are excessively hungry. In the later 
stages, however, they are often apathetic, and apparently 
too weak to perform voluntary movements. When they 
have reached this stage, they are subject to sinking 
spells — that is, periods in which their vitality is very low. 
These may become very alarming, and often result 
fatally. 

3. Vomiting is frequent. 

4. The hunger is often very great, and extremely dif- 
ficult to satisfy. 

5. Subnormal temperatures, ranging from 96° to 98° 
F., with an irregular daily curve, is the rule. The tem- 
perature can easily be raised to 100° F. or more by the 
application of artificial heat (hot-water bottles, etc.), and 



ATHREPSIA. 247 

can sink quite as rapidly and alarmingly when the arti- 
ficial heat is removed. 

6. The pulse is often slow and small, and the heart- 
beats weak, and often only one heart tone is heard at 
the apex. The blood is thin, pale, and has a low hemo- 
globin and red cell count. There may be a moderate 
leucocytosis. Collapse is likely to result from circula- 
tory failure, suddenly and without warning. 

7. Respiration becomes rapid, and the expirations pro- 
longed. The breathing becomes irregular, even to the 
Cheyne-Stokes type. 

8. The sensorium is not involved in these infants, and 
when not too weak they take cognizance of their sur- 
roundings, are alert, and sleep but little. 

9. The urine* usually shows an increased ammonia co- 
efficient. It may contain albumin, but very rarely sugar. 

10. The stools are variable, mostly dyspeptic, occa- 
sionally diarrheal. In the earlier stages and in periods 
of remissions they may be quite firm (soap stools), 
again soft and firm stools may alternate. The hunger 
stool — small, dark, and containing much mucus — is com- 
mon, especially in advanced cases, with an inability to 
take proper diet. Dark-brown, black, and tarry stools 
indicate, usually, hemorrhages from ulcers in duodenum 
(Helmholtz). We therefore learn to recognize the char- 
acter of the stools as being only of secondary importance 
in the diagnosis, and also of secondary importance for 
treatment. We must not be misled into further starva- 
tion because of temporary changes ■ in character, even 
for the worse, of the stool, due to the changes in the 
diet instituted for therapeutic purposes. 

11. These infants are peculiarly susceptible to infec- 
tions, and even slight infections of the skin, respiratory, 
gastro-intestinal, and genito-urinary tracts, may prove 
fatal. 

12. Edema, cyanosis, and a more or less generalized 
purpura are not infrequently forerunners of an impend- 



248 INFANT FEEDING. 

ing death. The development of edema, with correspond- 
ing gain in weight, may lead to the conclusion that the 
infant is improving. During this stage there is always 
great danger of the development of diarrheal complica- 
tions. 

13. Acidosis may develop and is probably in part due 
to the diminished volume flow of blood through the tis- 
sues, and to a lesser extent to the development of ace- 
tone bodies, the latter due in part to starvation. As 
there is usually no diminution in the amount of urine 
secreted when sufficient fluids are administered, the acido- 
sis is not due to an accumulation of urinary waste prod- 
ucts in the body. Acidosis is usually not a prominent 
feature. 1 

Diagnosis. The diagnosis in severe cases may be 
made from the clinical picture of the. condition, but it 
is necessary to exclude emaciation due to tuberculosis, 
syphilis and cachexia caused by other disease, and also 
by simple inanition, due to prolonged underfeeding. This 
is to be based on the history and examination of the 
infant. In lighter cases it is necessary to differentiate 
especially from disturbed metabolic balance and from 
simple dyspepsia, since the treatment which improves 
these conditions may do considerable harm in infants 
suffering from athrepsia. The status praesens is not 
sufficient for making the diagnosis, since, as previously 
mentioned, remissions with stationary weight and good 
stools often occur. In these cases the history is of ut- 
most importance : repeated diarrhea, loss in weight and 
febrile infections should lead one to suspect athrepsia. 
The positive diagnosis is made upon the reaction of the 
infant to food. If on somewhat increasing the diet a 
marked and severe paradoxical reaction appears (diar- 
rhea, loss of weight, and occasionally fever), athrepsia 
should be suspected. 



1 Marriott, \Y. McKim : Am. Jour. Dis. of Children, xx, 461, 
1920. 



ATHREPSIA. 249 

Prognosis. We must remember that while pri- 
marily the- picture of the disease is a nutritional one, the 
death is frequently brought about by infection. The 
younger the infant the greater is the mortality and this 
is most especially true during the first months of life, 
when breast milk is not obtainable. Among older in- 
fants the prognosis is better. The hygienic conditions 
under which the infant is treated and the care with which 
the treatment is carried out are important factors. On 
the whole, these infants do better in the home than in 
the general wards of institutions, due to the fact that 
they require a great deal of individual nursing care. In 
institutions there is also the possibility of infection 
through exposure. Convalescence is usually slow and 
may cover a period of several months in the severe types. 

The prognosis depends on the following factors : 
(1) The stage of athrepsia. When the loss of weight 
has reached one-third of the body weight (Quest's fig- 
lures), then the reparation, under any treatment, seems 
to be impossible. (2) The nature of the dietetic treat- 
ment, and especially the possibility of feeding with hu- 
man milk. If one avoids the common errors, even the 
severe cases may be saved, except when the treatment 
is started too late. (3) The extent of the lowered im- 
munity. The prognosis should always be guarded. 

Improvement is common, even in severe cases, but 
there is a great tendency to sinking spells and collapse. 
Death in these cases is sometimes remarkably sudden. 
It usually occurs in one of the following ways : ( 1 ) By 
sudden syncope. (2) By apparent paralysis of the res- 
piratory center. Periods of apnea usually precede the 
latter. There is no disturbance of consciousness. The 
face looks gray, and the eyes are staring. The breath- 
ing becomes irregular and slow, the heart weakens, the 
temperature sinks far below normal. Cyanosis increases, 
and breathing gradually stops. Sometimes the heart 
stops first. Such death may extend over days. 



250 [NFANT FEEDING. 

Treatment. Prophylaxis is the key-word to success- 
ful treatment. A recognition and proper interpretation 
of minor nutritional disturbances will avoid the graver 
conditions. 

For a proper conception of the therapeutic needs we 
must recognize : 

1. That we have a chronic condition which , is subject 
to acute catastrophes. 

2. That the younger the infant and the greater the 
preceding dietetic errors, the graver are the consequences 
of athrepsia. 

3. That starvation is dangerous. 

4. That food is assimilated with difficulty. 

5. That the downward weight-curve is likely to drop 
suddenly with improper feeding and intercurrent infec- 
tion. 

Three essentials are necessary to the successful treat- 
ment of the majority of cases of athrepsia: (1) Avoid- 
ance of prolonged starvation; (2) the administration of 
sufficient inert fluids, and (3) human milk. It is the 
misfortune of most of these infants to have their ab- 
normal stools — or more commonly, the hunger stools 
previously described — interpreted as an indication for 
starvation, regardless of the fact that the baby is already 
starving. It has been our experience not only to have 
seen one day of starvation, but repeated periods of 
starvation, the rule, because of misinterpretation of the 
significance of the "starvation stools." A single day of 
starvation is often sufficient to kill an advanced case, 
and even prolonged underfeeding, below 60 calories per 
kilogram (the amount required to sustain the body equi- 
librium), has a very harmful effect. Starvation from 
without is thus added to inanition from within. 

1. Water Administration. Athreptic infants must at 
all times receive sufficient fluids to meet their needs. 
They should, during the twenty-four hours, be given 
approximately one-fifth of their body weight in water, 



ATHREPSIA. 251 

including that contained in the food administered. The 
water or weak tea feeding should be set aside in a steril- 
ized bottle and given between feedings. 

2. Feeding With Hitman Milk. It must be given in 
moderate quantity, best guarded by drawing off and feed- 
ing, as these infants. drink too rapidly (always hungry), 
and do not stand large amounts. About 200 to 300 mils 
daily is enough to sustain the infants temporarily (70 
calories per kilogram is sustaining — Rosenstern). Feed 
often ; ten feedings may be given, one every two hours 
(20 to 30 mils), weak tea or saccharin water ad libitum 
between feedings. The daily quantity should be in- 
creased as rapidly as possible (at least every other day), 
until not later than after seven to ten days about 100 
calories (130 to 150 mils) per kilogram are administered. 
The number of feedings should gradually be decreased 
as the condition improves, and direct nursing on the 
breast may be tried later, but the danger of overfeeding 
must not be overlooked. There is usually little danger 
of overfeeding when there are no gastro-intestinal symp- 
toms and the diet consists exclusively of breast milk. 
Because of the decreased weight little can be expected 
in the way of rapid progress until the diet reaches a 
quantity which would approximate 100 calories per kilo- 
gram for the average full-weight infant at a given age, 
which not infrequently means 150 to 200 calories per 
kilogram for the athreptic infant. The diet should be 
steadily increased as long as there are no gastro-intestinal 
disturbances. 

Weight may still not improve for some time. This 
Keller calls "reparation stage." Even on feeding with 
human milk there is a shorter or a longer period of 
stationary weight (depending on the severity of the 
case), which, however, is accompanied by improvement 
of the symptoms. Those who have not had. experience 
in these cases may be inclined to blame the wet-nurse, 
and advise a change. In the stage of reparation, how- 



252 INFANT FEEDING. 

ever, the body is being reconstructed, without being able 
to put on weight, this being partially, at least, due to 
still deficient absorption, and partially also to the fact 
that the human milk, containing comparatively small 
quantities of proteins and salts, furnishes only a limited 
quantity of material for rebuilding of the body. Only 
after this period the gain in weight "begins and it may be 
shortened by feeding daily 100 mils of boiled buttermilk 
or skim milk, which is rich in salts and proteins, both of 
these substances hastening weight increase. This is not 
to be done until after the second or third week of treat- 
ment, and with a close observation of the results. It 
may be fed by mixing with and distributing through the 
expressed breast milk. 

It may be necessary to add carbohydrates to the breast 
milk, more especially when the quantity at hand is in- 
sufficient. This should be done with considerable care, 
the daily quantity added being increased by four to eight 
grams at a time. This may be given in the form of cane 
and milk sugar or corn syrup. In older infants the 
cereal gruels may be added to the diet during the repara- 
tion stage. 

The complete recovery is not to be expected sooner 
than in two to three months. And only then should the 
return to artificial feeding be thought of. The weaning 
should be preceded by experimental administration of 
a small quantity of whole cow's milk, as there is a pos- 
sibility of idiosyncrasy to cow's milk. 

3. Artificial Feeding. If there is no possibility of 
feeding an infant suffering from athrepsia otherwise 
than with artificial food mixtures, then much the same 
rules are to be followed as have been given for diar- 
rheal disturbances. As has been previously stated, there 
is a great need for food and there always exists the 
danger of overfeeding, which holds particularly true in 
those who must be put upon artificial diet. We must, 
therefore, often be satisfied with a very slow stage of 



ATHREPSIA. 253 

reparation and expect little gain in weight until the in- 
fant is able to assimilate sufficient quantities of food, 
which may mean a diet with food value considerable 
over that required by the normal infant. Our best re- 
sults have been obtained by the administration of whole 
and skim lactic acid milk and albumin milk (protein). 
The two latter foods, however, have a very low caloric 
value, which must be increased by the addition of sugar 
and starch. 

It may be necessary to use boiled whole or fresh skim 
milk when the lactic acid milk or albumin milk is not 
available. The feeding with these foods will be de- 
scribed in detail. Whenever possible lactic acid milk 
should be used as the basis of the feeding. The feeding 
may be started with fat-free lactic acid milk to which 
small quantities of carbohydrates have been added. This 
may be followed by a feeding with equal parts of whole 
and fat-free lactic acid milk. 

In mild cases feedings of 60 mils (2 ounces) eight 
times daily, and in severe cases ten or twelve feedings 
of 30 mils (1 ounce), may be given in twenty-four hours 
during the first two days. 

Gradually the fat-free may be replaced by whole lac- 
tic acid milk until these infants receive one-fifth or one- 
sixth of the body weight of this food per day. In very 
young infants the change to whole lactic acid milk must 
of necessity be somewhat slower. 

The carbohydrates are usually added in a slowly fer- 
mentable form, such as the maltose and dextrin com- 
pounds, which are usually started by the addition of four 
grams per kilogram (two grams per pound) and in- 
creased until eight grams or more per kilogram of body 
weight are added. The flour ball or dextrinized barley 
flour may be used to further supplement the carbo- 
hydrates by the addition of an amount equal to one-fourth 
of that of the sugar added. 



254 INFANT FEEDING. 

Marriott has more recently recommended the use of 
commercial "glucose," otherwise known as "corn syrup," 
which is a mixture of dextrin, glucose and maltose, as 
an available form- of carbohydrate in use in these cases. 
Of the total carbohydrates present in corn syrup dex- 
trin makes up approximately 55 per cent., maltose 30 
per cent., and glucose 15 per cent. He starts the diet 
by the addition of 3 per cent, to the lactic acid milk and 
if no diarrhea occurs, he increases it gradually, depend- 
ing upon the infant's tolerance and the amount of food 
necessary to cause a gain in weight. In some infants 
the amount of added sugar may advantageously be as 
high as 10 per cent. 

Infants may be fed on these corn syrup, lactic acid 
milk mixtures for an indefinite period of time. As a 
gain in weight occurs the amount of sugar may be ad- 
vantageously diminished. In infants approximating one- 
half of their normal weight it may be necessary to feed 
as much as 160 to 200 calories per kilogram before there 
is a marked increase in weight. Several weeks of care- 
ful feeding may be required before these amounts can 
be approximated. The whole lactic acid milk and corn 
syrup mixtures owe one of their chief advantages to the 
fact that they are a concentrated food and if the infant 
can take only, a limited number of ounces at a feeding 
and only a limited number of feedings in a day, the 
requirements for a high caloric intake can be solved by 
the administration of such a mixture. A mixture made 
from whole milk to which the corn syrup is added will 
have a food value varying from 25 to 30 calories or 
more per ounce, depending upon the amount of the syrup 
added. 1 



1 Karo — blue label syrup contains from 80 to 85 per cent, of 
carbohydrate by weight, as its specific gravity is high (ap- 
proximately 1.40), it contains from 110 to 120 per cent, of carbo- 
hydrate by volume. The thick syrup is somewhat difficult to 
handle and to mix with milk. It is more convenient to prepare a 
diluted syrup. Mixing 45 volumes of the thick syrup with 55 
volumes of water gives a thin syrup containing approximately 50 



ATHREPSIA. 255 

The individual meals should be increased so as to meet 
the infant's caloric needs as rapidly as the condition 
allows. 

The need of the athreptic infant for food containing 
sufficient vitamines can be demonstrated clinically by the 
rapid improvement noted upon the proper rounding out 
of the diet. For this reason the infant should not be 
kept for too long a time on a food deficient in this sub- 
stance. Cod-liver oil should be added to the diet, be- 
ginning in small amounts, as soon as the infant's con- 
dition will warrant it. Orange juice should also be 
started early and increased until one ounce or more is 
taken daily. 

Good results in the treatment of athreptic infants are 
obtained by feeding them with albumin milk. 

The advantage of the treatment with albumin milk 
consists in the fact that it is possible to reach sufficient 
feeding quantities more rapidly* than with most other arti- 
ficial foods, without the danger of exciting anew the fer- 
mentative processes. Thereby the danger of inanition is 
avoided and reparation is accelerated. 

In the mild cases of athrepsia we start after an inter- 
val of six hours on tea, with administration of 300 mils 
of albumin milk, with an addition of 3 per cent, of 
maltose-dextrin preparations (milk-sugar is not advis- 
able, and even the cane-sugar is not so reliable), divided 
into five or six meals, and with further addition of 
tea. In the days that follow, without paying any at- 
tention to the stools, the quantity of albumin' milk is 
increased, every other day by 100 mils. In the presence 
of firm stools it is increased even more rapidly, until a 
daily quantity of 180 to 200 mils per kilogram (3 ounces 



per cent, of carbohydrate. One hundred c.c. of this by volume 
may be considered as containing 50 Gm. of carbohydrate. Such 
a thin syrup is measured in a graduate and added to the whole 
lactic acid milk. The mixture should not be agitated sufficiently 
to separate the fat as butter. The mixture is not further steri- 
lized, but is kept in a refrigerator until used. As such mixtures 
are very thick, a nipple with a large hole must be used in feeding. 



256 INFANT FEEDING. 

per pound body weight) is reached. A total daily quan- 
tity of 1000 mils of albumin milk is rarely to be ex- 
ceeded. In typical cases dry fat-soap stools appear after 
one to two days, this is followed by cessation of weight 
loss, and reparation proceeds undisturbed. 

After tbe quantity of food necessary to sustain the 
infant is reached, sugar may be gradually increased 
from 3 to 5 per cent. Dextrinized starches in tbe form 
of flour ball (imperial granum), or dextrinized barley 
flour in quantities of 1 or 2 per cent, of the mixture, can 
often be added, to advantage, to albumin milk. 

In severer grade of athrepsia the intestine is allowed 
to empty itself by a short period of hunger. In spite of 
the danger of inanition, six, or at most twelve, hours on 
tea cannot be avoided. This is to be followed by the 
administration of albumin milk, best by frequent meals 
(eight to ten ), on the first day 200 to 300 mils, and then, 
as previously advised, rapid increase with gradual dimi- 
nution of the number of meals and increase in the addi- 
tion of carbohydrates. If the initial loss in weight does 
not stop within three to four clays, and if the child shows 
languor and tendency to subnormal temperature, then 
the addition of carbohydrates must be increased, even 
in the presence of frequent stools, until the loss stops. 

If we proceed in this way, then the number of un- 
successful cases becomes considerably less. Experi- 
ence has shown that in albumin milk therapy often an 
error is made which frequently leads to failure by under- 
feeding. It should be remembered that albumin milk 
has a caloric value of only about twelve to the ounce, 
and therefore this feeding must be carefully guarded to 
avoid : ( 1 ) Too slow initial increase, thereby prolonging 
inanition; (2) omission of carbohydrates or insufficient 
increase of the same; (3) repeated restriction of the 
quantity of the food, or withholding carbohydrates when 
the temperature rises or diarrhea reappears. All these 
are to be avoided. Only when sudden loss in weight 



ATHREPSIA. 257 

and violent diarrhea set in, should the total quantity of 
the food be reduced. After disappearance of these acute 
symptoms the increase must be made as soon as possible. 

In the beginning of the treatment with albumin milk, 
exacerbations similar to those that occur on feeding with 
human milk may occur, and these should not lead to 
starvation. Later, the gain is rapid, provided that suf- 
ficient quantities of carbohydrates have been added. 

The duration of feeding with albumin milk is about 
six to eight weeks for the younger infants, and four to 
six weeks for the older infants. After this time the 
conditions change usually to such an extent that ordinary 
milk mixtures, corresponding to the child's age and 
weight may well be taken. The change is best made by 
replacing all the feedings of albumin milk mixtures at 
one time by a weak boiled milk mixture. This is fre- 
quently followed by bad stools for a day or two, which 
should not lead one to discontinue the new diet. The 
quantity, however, should not be further increased until 
they show some improvement. 

If a relapse occurs, then it is necessary to return to 
feeding with albumin milk for some additional time. 

One may speak of a complete cure of this nutritional 
disturbance in an infant only when, after discontinua- 
tion of albumin milk and return to the usual milk mix- 
tures, with careful dosage, the development proceeds 
without any disturbance. 

Medicinal Treatment. This is practically limited to 
stimulation in the presence of collapse and sinking spells, 
and the favorite stimulant is camphor given intra- 
muscularly in the form of a sterilized camphorated oil 
(five to ten drops every two to four hours). Aromatic 
spirits of ammonia and caffeine sodium benzoate are 
valuable. Epinephrin, in doses of three to five minims of 
Kooo solution, administered intramuscularly, may be used 
in an emergency in repeated doses. In the severer types 
blond transfusion is also indicated. 

17 



258 INFANT FEEDING. 

After-treatment. In extreme cases intravenous in- 
jection of glucose solution may be used to advantage. It 
increases, at least temporarily, the volume of the blood, 
and as a result the volume flow through the organs and 
at the same time furnishes a limited amount of food 
which may be of considerable value in extreme cases. 

Glucose may be administered intravenously in 10 per 
cent, solution, in amounts not exceeding 20 mils per kil- 
ogram of body weight. It is best given in normal saline 
the total amount not to exceed 100 to 200 mils. (% °f 
the body weight ) . It may be preceded to great advantage 
by giving 150 to 300 mils of Ringer solution intraperitone- 
ally one hour before. The injection should be given very 
slowly, and may be repeated two or three times a day. 

Artificial heat must be applied in all cases with a 
decided tendency to low temperatures. This must not 
be overdone, since the child's temperature can easily be 
raised above the normal, and act as unfavorably as sub- 
normal temperature. 



CHAPTER VI. 
ANHYDREMIA (ANHYDREMIC INTOXICATION). 

Synonyms: Alimentary intoxication (Finkelstein). 
Alimentary toxicosis (Czerny). Gastro-enteric intoxi- 
cation (Holt). Catarrhal enteritis, ileo-colitis, infec- 
tious diarrhea, cholera infantum, summer diarrhea. 

The term anhydremia (an-privative, hydro-water, 
aima-blood) means the opposite of hydremia, an abnor- 
mal decrease in the relative proportion of the water to 
that of the salts of the blood. This term, suggested by 
Marriott, 1 is used to describe a general toxic state pre- 
cipitated by an insufficient water intake or an excessive 
loss through diarrhea and vomiting, and by way of the 
skin and lungs, and resulting in a negative water balance 
and a diminished blood volume. It is characterized by 
a symptom-complex in which diarrhea and irritability 
of the central nervous system are the most characteristic 
signs. The collapse and nervous symptoms may out- 
weigh the intestinal symptoms. Less frequently cases 
may be seen unassociated with diarrhea and which are 
due to insufficient fluid intake. 

The graver the preceding nutritional disturbances, 
that is, the closer the infant approaches the stage of 
athrepsia, the more readily does the stage of anhydremic 
intoxication develop. 

Etiology. The symptom complex has as its basis 
a desiccation of the blood and tissues, the result of an 
increased excretion of water over the intake. The end 



Note 1 : In the elaboration of Chapter VI free use has been 
made of the original articles of W. McKim Marriott. See Patho- 
genesis of Certain Nutritional Disorders, Proceedings of American 
Pediatric Society, xxxi, 1919; Some Phases of Pathology of Nu- 
trition in Infancy, Am. Tour. Dis. of Children, xx ; 461, Dec. 1920; 
Severe Diarrhea in Infancy, M. Clinics, N. Amer. iv, 717; Novem- 
ber, 1920. 

(259) 



260 INFANT FEEDING. 

results of this abnormal metabolism is a characteristic 
group of symptoms which are in large part directly at- 
tributable to the concentration of the blood and its effect 
upon the function of the other organs. 

The group of symptoms are suggestive of an acute 
poison which may result in death and in the majority 
of instances leave no demonstrable pathological findings. 
In the absence of anatomical changes we are forced to 
conclude that some profound alteration in the chemical 
or physiological processes in the body must have oc- 
curred. Czerny, who gave this clinical picture consider- 
able thought, believes that it was the result of the ab- 
sorption of toxic substances of metabolic or bacterial 
origin. Finkelstein believed that it was primarily due 
to food poisoning and that infection and constitutional 
abnormalities acted as contributory factors to the lower- 
ing of the infant's tolerance for food, thereby impairing 
his ability to utilize food without the production of 
harmful substances. They base their conclusions upon 
the fact that the clinical picture is aggravated when a 
relative excess of food is given to this class of infants. 
Marriott, in his analysis of this group of cases, recog- 
nizes the bad effect of food when given in excess of the 
infant's tolerance but explains it upon a different basis. 
He emphasizes the well known fact that infants suffer- 
ing from diarrhea have a tendency to become worse when 
food is given, especially an excess of carbohydrate or 
fat. The result of this is an increase in the degree of 
anhydremia. If food is given to an infant who is an- 
hydremic, such as a case of athrepsia, even though 
diarrhea is not present, it is likely to result in diarrhea. 
It is therefore evident that any of the etiological factors 
which may cause or predispose to diarrhea may be the 
forerunners of the stage of anhydremia. due largely to 
the loss of fluids through the bowels and to a lesser 
degree through vomiting. The secondary picture of 
acidosis may be superimposed upon that of anhydremia 



ANHYDREMIA. 261 

with clinical evidence of an intoxication. The acidosis 
in these cases is due to a deficient renal function second- 
ary to the impaired circulation through the kidneys and 
results in an accumulation of acid phosphates in the 
blood. 1 A second factor may be active in the develop- 
ment of the acidosis, in that there is a tendency toward 
accumulation of lactic acid in the tissues from partial 
cell asphyxia which is also dependent upon the dimin- 
ished blood flow secondary to a diminished blood volume. 
Uremia may be superimposed in this stage. We believe 
that we are justified in assuming with Marriott that the 
absorption of unsplit sugars into the blood through in- 
jury of the intestinal mucosa and the products of fat 
metabolism, as suggested by Finkelstein, are not the 
underlying etiological factors. However, sugar may in- 
crease the symptoms of intoxication through increasing 
the diarrhea and water loss. Fats and salts may have a 
similar action. Sugar further furnishes a good culture 
medium for the growth of abnormal bacteria and for the 
normal intestinal bacterial flora which under abnormal 
conditions may inhabit the upper intestinal tract. The 
abnormal flora may enter from above through infected 
food or ascending from below to higher levels, they may 
invade the upper area in the small intestines in abnormal 
numbers, due to diminished resistance of the individual. 
Again, in disturbed metabolism an excess of sugar may 
reach the lower bowel and stimulate abnormal bacterial 
activity. It is also possible that the protein split product 
(amino-acids) may give rise to abnormal amounts of 
histamine and allied substances which are very irritating 
to the intestinal mucosa and thereby cause or aggravate 
the diarrhea. It is therefore evident that all factors 
which cause nutritional disturbances can be active fac- 
tors in the causation of a state of anhydremia with its 



1 Marriott, W. McKim and Howland, J.: The influence of 
acid phosphate on the elimination of ammonia in the urine, 
Arch, of Int. Med., xxii, 477, 1918. 



262 INFANT FEEDING. 

secondary picture of intoxication. Although frequently 
the underlying diarrhea is due to a primary food dis- 
turbance the diarrhea is more commonly seen following 
a food disturbance secondary to some other factor. 

Anhydremia also frequently occurs in the absence of 
diarrhea when the amount and character of the food is 
not such as to cause a gastro-intestinal disturbance and 
as a secondary complication in infections. It is espe- 
cially common in premature infants who are not given 
sufficient inert fluids between feedings, in young infants 
nursing dry breasts and in the presence of anorexia in 
the course of acute illnesses. It is a common condition 
among infants suffering from intra-cranial lesions, such 
as intra-cranial hemorrhages, and idiots. Also in the 
course of acute infections, such as pneumonia, otitis 
media and pyelitis, more especially during the acute 
febrile stages associated with delirium. In all of the 
foregoing, vomiting may be an active factor. 

Desiccation of the body may therefore occur in a great 
variety of conditions and the symptoms are essentially 
the same, no matter what the original cause, and while 
diarrhea is by far the most frequent etiological factor, 
it need not necessarily be present. In the light of our 
present knowledge the terms "anhydremia" and "anhy- 
dremic intoxication," as suggested by Marriott, are ac- 
curately descriptive, the former of the underlying fac- 
tor and the latter when the toxic stage has been reached, 
irrespective of the original cause. 

Symptoms. Fever. A rise in temperature is one of 
the first symptoms. It may be slight, or it may go up 
to 104° or even 106° F. The height of the temperature 
is not always a direct indication of the severity; in fact, 
the several types associated with athrepsia may have a 
low temperature. Prompt withdrawal of the food in 
cases unaccompanied by infection is usually as quickly 
followed by a lower temperature when at the same time 
there is sufficient water administration and retention. 



ANHYDREMIA. 263 

However, if the offending food is continued, we soon 
have other symptoms suddenly and to an alarming de- 
gree. The weight of evidence seems to strongly support 
the view that the action of the administration of hyper- 
tonic solutions of sugars or salts is to remove water 
from the body with resulting further dehydration. The 
assumption of Finkelstein, that the continuing of the 
diet resulted in the production of pyrogenic metabolites, 
is not tenable. Fever as the result of dehydration has 
been repeatedly observed, such desiccation resulting in 
interference with water evaporation through a decreased 
circulation and secondarily by interference with excre- 
tion. The second factor of infection leading to diarrhea 
and vomiting, and dehydration of the body is an added 
causative factor in the explanation of the fever. 

Rapid loss in weight, even one to two pounds in a few 
days. This is mainly due to loss of salts and water. 

Vomiting is frequent and may contain blood if long 
continued. 

The stools are liquid, usually numerous, and contain 
mucus, and occasionally blood. In the severest cases — 
cholera infantum — the stools assume a rice-water ap- 
pearance, move almost continuously, and are often asso- 
ciated with tenesmus, and not infrequently prolapse of 
the rectum. Exceptionally, an obstipation is seen in 
place of the diarrhea, and when this is associated with 
vomiting and abdominal distention, one cannot help but 
think of intestinal obstruction. 

The general appearance of the patient changes. The 
skin is gray in hue, and becomes wrinkled ; the eyes are 
sunken, with distant stare, and the nose assumes a 
pinched appearance. The skin hangs in loose folds ; it 
is dry and has lost its elasticity so that it may be picked 
up into ridges which remain an appreciable interval be- 
fore flattening out. The lips are dry, parched and often 
of a peculiar cherry red color. The mouth is held partly 
open, the tongue is dry. 



264 INFANT FEEDING. 

Nervous symptoms and psychic disturbances are usu- 
ally pronounced, and often lead to a confusion with 
meningitis. The infant is restless; the sensorium is dis- 
turbed, with an occasional cry as if in pain. Before 
these more severe symptoms develop, the child appears 
apathetic, drowsy, and dopy. The face assumes a fixed 
expression, and there is a tendency on the part of the in- 
fant to lie constantly in one position, and when the child 
moves its extremities it does so slowly, as if too tired or 
weak to change its position. The arms are not infre- 
quently flexed in an attitude resembling that of a prize 
fighter. If the condition increases in severity, stupor and 
coma, associated with twitchings, convulsions, strabismus, 
and other meningeal symptoms, ensue. 

The respiratory manifestations may vary from a slight 
increase in number and depth to a marked dyspnea. The 
respirations are often of the "air hunger" type, such as 
is observed in diabetic or uremic coma (deep, rapid and 
without pause). The breathing becomes both costal and 
abdominal, the whole thorax rises with each inspiration 
and accessory muscles are brought into play. This is 
due to acidosis, which is, however, not the result of an 
overproduction of acetone bodies, but, as demonstrated 
by Howland and Marriott, 1 it is caused by a failure of 
the kidneys to excrete acid phosphate and in part to acids 
produced in the tissues as a result of diminished oxida- 
tion due to the deficient blood circulation. 

The urine is small in amount, even to anuria. It may 
contain albumen and not infrequently casts. The kidneys 
become functionally inactive, although there are usually 
no demonstrable pathological changes. This alteration 
in the functional capacity of the kidney results in the 
accumulation in the blood of products ordinarily elimi- 
nated by the urine. Uremic symptoms are not infre- 
quent as a result. Occasionally glycosuria is present. 



1 Howland and Marriott: Am. Jour. Dis. of Children; 11, 
309, March, 1916. 



ANHYDREMIA. 265 

Schloss 1 found the sugar in the urine to be either glu- 
cose alone or glucose in co.nbination with galactose or 
lactose. A certain amount of lactose can pass through 
the intestinal mucosae and it may well be the case that 
when fairly strong solutions of lactose are introduced 
into the intestinal tract of these infants that some would 
be absorbed unchanged. As lactose is not altered out- 
side of the intestine, it would be excreted quantitatively 
in the urine. It has been shown by Araki 2 that as- 
phyxial conditions occurring as the result of vasocon- 
striction, hemorrhage, or a diminution of the oxygen 
carrying capacity of the blood, lead to glycosuria. This 
is generally supposed to be the result of increased glyco- 
genolysis, dependent upon acid production in the tissues. 
In the case of these infants the glycosuria may be readily 
explained on the same basis. 3 Schloss has demonstrated 
an excess of urea and total non-protein nitrogen in the 
blood, reduced phenolsulphonephthalein excretion in the 
urine and an abnormally high Ambard co-efficient as 
evidence of impairment of renal functions. He also 
found that the extent of renal function involvement 
was proportionate to the degree of desiccation of the 
blood. 

The Heart: Action is weak and the pulse is small, 
often rapid and irregular. 

The Blood presents changes which are characteristic 
and constant, varying only in degree. The changes are 
dependent upon the severity of the case. In the severer 
cases the blood is obtained with difficulty due to the 
fact that it is thick and does not flow easily, and when 
centrifuged separates a relatively small amount of scrum. 
These findings are due to the fact that it is concentrated 
by water loss. The specific gravity is increased, as is 



i Schloss, O. : Am. Jour. Dis. of Children, xv, 165, 1918. 
2 Araki : Ztschr. Physiol. Chcm., Scries of articles in 15, 16, 
17, 19. 
-Marriott: Am. Jour. Dis. of Children, xx, 461, 1920. 



266 INFANT FEEDING. 

also the index of refraction. There is a negative nitro- 
gen and salt balance. The viscosity, the electrical con- 
ductivity and the osmotic pressure are all increased. The 
state of uremia, so frequently seen in the fatal cases, 
may be a direct result of the increased colloidal osmotic 
pressure of the blood over the arterial pressure in the 
renal glomeruli, which results in decreased secretion of 
urine by the kidneys. Diminished blood volume results 
in a greatly diminished volume flow of the blood. There- 
fore, less blood flows through a given portion of the 
body in a unit of time. This leads to an accumulation 
of acid products of metabolism in the tissues and a de- 
creased alkali reserve of the blood, that is to say, acid- 
osis. The blood flow in the arms of normal infants, 
measured by the Stewart method, by Marriott, ranged 
from 15 to 22 mils per 100 Gm. per minute. In some 
infants suffering from anhydremia he found it as low 
as 2 or 3 mils per minute. The blood pressure is usually 
maintained through the high blood viscosity. A com- 
parison of the red blood cell counts, made on venous and 
capillary bloods, shows a marked concentration of cor- 
puscles in the capillaries. This stagnation of red blood 
cells in the capillaries, as the result of arteriolar con- 
striction, may explain the peculiar gray pallor of the 
skin, which tends to disappear with the establishment of 
a normal circulation. The leucocytosis, which is almost 
invariably present, may in part, at least in the uncom- 
plicated cases, be clue to a damming back of the leuco- 
cytes in the capillary blood. In those complicated by 
infection a higher count is often seen, ranging from 15 
to 35. 

Sclerema is present in the severer types — a very bad 
sign — due to a coagulation of tissue fluids of an unknown 
nature. 

Enlargement of the liver accompanies the severe types. 

Pathogenesis. As has been stated, a great .deal of 
thought has been given to the clinical picture which has 



ANHYDREMIA. 267 

been described, both in American and European clinics. 
There has been a considerable difference of opinion as 
to the underlying factors influencing the train of symp- 
toms. In the well-developed case a large number of 
symptoms are regularly and coincidentally present and 
it has been the object of the various clinicians to find 
an adequate explanation for all of the symptoms. The 
clinical picture in those infants who have lapsed into 
a toxic condition following severe diarrhea may be ex- 
plained on the basis of the water and salt losses from 
the body. In all probability there is also a deep-seated 
change in the water binding functions as a result of the 
loss of salts and the breaking down of glycogen neces- 
sary to meet the metabolic functions during the period 
of under-feeding. Unfortunately, this increased water 
and alkali loss by the intestines is not balanced by les- 
sened kidney secretion until the renal function itself is 
impaired through circulatory disturbances. There is also 
an increased water loss through the lungs and tempo- 
rarily at least in the presence of fever, through the skin. 
Once anhydremia has occurred "a vicious circle" is es- 
tablished which still further results in lowering the func- 
tional capacity of the gastro-intestinal tract. Even in 
the absence of diarrhea there is an interference with the 
functional capacity of the intestines, with a resulting 
increased decomposition of food, the products of which 
may cause further injury to the intestine itself. Follow- 
ing this there may be an absorption of bacterial poisons 
from the intestines which may result in a toxic catas- 
trophe. When diarrhea is present the administration of 
food has a tendency first to irritate the intestine, more 
especially when hypertonic sugar solutions are adminis- 
tered ; salts, fats and proteins may have a similar action. 
The absorption of the soluble metabolites, by their ac- 
cumulation in the blood, increases its osmotic pressure 
and thereby decreases the available water reserve. Mar- 
riott believes that these facts are an adequate explana- 



268 INFANT FEEDING. 

tion of Finkelstein's observation, that the giving of food 
increased the symptoms of his infants suffering from 
alimentary intoxication. It is quite likely that interfer- 
ence with the function of the liver becomes an important 
factor and the absorption of its by-products may aggra- 
vate the fever and diarrhea. 

The secondary picture of acidosis may be superim- 
posed upon that of anhydremia with clinical evidence of 
an intoxication. The acidosis in these cases is due to a 
deficient renal function secondary to the impaired cir- 
culation through the kidneys and results in an accumula- 
tion of acid phosphates in the blood. A second factor 
may be active in the development of the acidosis, in that 
there is a tendency toward accumulation of lactic acid 
in the tissues from partial cell asphyxia which is also 
dependent upon the diminished blood flow secondary to 
a diminished blood volume. Uremia may be super- 
imposed in this stage. The state of acidosis' is respon- 
sible for the '*air hunger'' type of respiration. 

Marriott and Perkins made a series of investigations 
to ascertain the presence of a negative water balance in 
two groups of cases, the first unassociated with diarrhea 
and the second with diarrheal disturbances, to prove that 
the symptoms in both groups were associated with simi- 
lar blood findings. As a criterion of the degree of desic- 
cation of the body fluids they determined the index of 
refraction of the blood serum. This determination is 
easily made and requires only one or two drops of serum. 
It has the advantage that it may be repeated at frequent 
intervals. The refractive index varies with the concen- 
tration of solids in solution. As the protein has much 
greater effect on the index than the other solid constitu- 
ents of the serum, it is possible to determine quite ac- 
curately the protein content of the serum by means of 
tne refractometer. The protein content of the serum 
of normal infants during the first six months of life 
averages about 6 per cent. — toward the end of the first 



ANHYDREMIA. 269 

year it is often as high as 7 per cent. 1 2 Marriott and 
Perkins 3 observed an increase in the protein content of 
the serum of as great as 50 per cent, above the normal 
for the age. They were able to demonstrate a state of 
anhydremia in conditions unrelated to diarrhea, such as 
pneumonia, otitis, pyelitis and non-infectious conditions 
in which food is refused, as well as in diarrheal disturb- 
ances. 

Pathology. In the small intestine there is usually 
no marked change. Hyperemia of the mucous mem- 
brane and enlarged follicles, especially Peyer's patches, 
are usually present. The liver and kidneys show a hy- 
peremia, cloudy swelling, and fatty degeneration (prob- 
ably causing hepatic and renal insufficiency). Other 
tissue changes which may be present are not specific but 
such as might be expected from similar noxas acting at 
any time. 

Diagnosis. The diagnosis is based on the above 
symptoms, and improvement on withdrawal of food, 
in the presence of a sufficient water administration by 
mouth, subcutaneously, intravenously or intraperitoneally. 
The most characteristic and striking symptoms are those 
of the nervous system resulting in stupor, pauseless res- 
pirations, and a toxic appearance. These are usually 
associated with diarrhea, vomiting and a rapid loss in 
weight. The history of preceding nutritional disturb- 
ances and infections are of great importance in diagnosis. 

Prognosis. The prognosis in anhydremia depends 
upon the underlying causes, the degree of desiccation 
and the previous nutritional condition of the infant. 
When anhydremia is due simply to insufficient fluid in- 
take it usually clears promptly after a sufficient amount 
of water has been taken by mouth. Anhydremia re- 
sultant from diarrhea or the combination of vomiting 



1 Reiss: Jahrb. f. Kinderh., lxx, 311, 1909. Ergcb. d. Inn. Med. 
u. Kinderh., x, 531, 1913. 
2 Salge: Ztschr. f. Kinderh., 1911, pp. 126, 317. 
3 Personal communication. 



270 INFANT FEEDING. 

and diarrhea is more serious than that due to other 
causes. The prognosis is especially bad in the case of 
infants already athreptic. The presence of acidosis ren- 
ders the prognosis exceedingly grave, not so much on 
account of the acidosis itself, for that can be cured, but 
because the presence of acidosis indicates that extreme 
desiccation has occurred, with profound disturbance of 
the metabolism. 

As infections, both parenteral and enteral, are com- 
monly the underlying causative factor, the further dan- 
gers from this source must not be under-estimated and 
further treatment must be directed to their relief. The 
prognosis is also directly dependent upon the ability of 
the infant to retain a sustaining diet after the subsidence 
of the acute toxic symptoms. The younger the infant, 
the more difficult will be the problem unless breast milk 
be available. 

Treatment. In the presence of vomiting and diar- 
rhea, more especially when they are complicated by an 
inability to retain sufficient inert fluids, every effort 
should be made early in their treatment to prevent the 
development of anhydremia. Vomiting and diarrhea 
are to be treated as previously recommended. (Page 
230). 

All food should be withdrawn for from six to twelve 
hours and in some cases as long as twenty-four hours. 

Sufficient water must be administered to overcome the 
loss from all causes. The average infant, in the pres- 
ence of vomiting, diarrhea and fever, will require a 
minimum of one-fifth of its body weight in water in 
twenty-four hours. In order to estimate the amount 
administered, a careful record must be kept of the 
amounts given and retained. 

As much as possible should be given by mouth in small 
feedings at frequent intervals. Water given immediately 
after vomiting is frequently retained. 



ANHYDREMIA. 271 

A single gastric lavage is indicated if food has been 
given shortly before or in the presence of repeated 
vomiting. 

In severe types subcutaneous injection of saline solu- 
tions, two or more times daily, are indicated, 100 to 300 
mils can be injected each time. Ringer's solution may 
be used to advantage for this purpose. 

Gm. or Mil. 

NaCl 7.5 

KC1 0.1 

CaCl 0.2 

Water 1000.0 

The water used in making this solution should be re- 
distilled shortly before using. 

The same solution may be administered intravenously 
in young infants through the longitudinal sinus and in 
older infants into the anterior jugular or median basilic 
vein. It should, however, be remembered that there is 
danger of collapse from acute cardiac dilatation when 
excessive amounts are introduced rapidly into the circu- 
latory system. On the average an amount not to exceed 
y 50 of the body weight should be injected at one time. 
The gravity method should be used. The danger of ad- 
ministering fluids by way of the longitudinal sinus must 
be appreciated. 

Probably the most efficient means of introducing water 
into infants of this type is by way of the peritoneal 
cavity. This method of administration was first used 
extensively in this country by Howland, 1 after seeing 
its successful application by Garrod, in London. 

Large amounts of fluid may be given this way and be 
rapidly and completely absorbed. Ringer's solution is 
the best for this purpose, and should be freshly sterilized 
before using. The injection is easily given and causes 
very little pain or discomfort. The needle used for the 

1 Blackfan, K. D. and Marcy, K. F. : Am. Jour. Dis. of Chil- 
dren, vol. xv, 19, 1918. 



272 INFANT FEEDING. 

injection should not be very sharp. A suitable size is 
18 gauge, which is about the size commonly used for 
serum injections. Strict aseptic technique is absolutely 
essential. There is but little danger of puncturing the 
intestine, if the method described is carefully followed. 
This route of fluid administration should not be under- 
taken unless all details can be fulfilled. 

The technique is as follows: If abdominal distention 
is present, this must first be relieved. The patient lies 
in the recumbent posture, with the movements of arms 
and legs restricted by a restraining jacket. The most 
favorable site for the introduction of the needle is 
through the linea alba, just below the umbilicus. The 
skin is prepared after the usual surgical method, with 
iodin and alcohol, and the area may be rendered anes- 
thetic with ethyl chlorid. The solution is introduced by 
gravity from an infusion bottle, only slightly elevated. 
It should be introduced at about 100° F. When the 
patient is restrained in the proper position and the site 
for the injection prepared, the skin and subcutaneous 
tissues are picked up between the thumb and the index 
finger, and the needle, pointing upward, is inserted at 
an oblique angle. After it has penetrated the peritoneum 
the fluid is allowed to flow into the peritoneal cavity. 

The injection of the fluid is continued until the abdo- 
men becomes slightly distended. It should not be in- 
troduced too rapidly or in too large quantities, to avoid 
the possibility of embarrassing the respiratory and cir- 
culatory systems. Two hundred to 500 mils can be in- 
troduced in from fifteen to twenty minutes. After the 
fluid has been introduced, the needle is withdrawn and 
the puncture wound covered with a sterile dressing. The 
injection may be repeated after six to twelve hours, if 
necessary. With repeated injections, even with an iso- 
tonic solution, there develops an edema of the peritoneum 
and frequently some exudate. This disappears without 
untoward effect. However, with the use of hypertonic 



ANHYDREMIA. 273 

solutions more serious injury of the peritoneum may 
result. We have therefore discontinued the use of glu- 
cose and bicarbonate of soda in the solution. 

If the infant presents evidence of acidosis, dextrose 
should be added to the saline solutions and administered 
intravenously. Six Gm. (90 gr.) of dextrose may be 
added to 120 mils (4 ounces) of saline solution and re- 
peated in four to six hours, if indicated. Pure dextrose 
is essential. Only rarely is there an indication for the 
administration of alkali. It should be remembered that 
intravenous administration of larger amounts of sodium 
bicarbonate may result in collapse. (See Acidosis.) 

Saline per rectum is best administered by the drop 
method unless the infants are too restless. Thirty drops 
per minute for four hours is 450 mils. One-half 
strength of Ringer's solution may be used. Sodium bi- 
carbonate, 5.0 Gm. (75 grs.) may be added to every 500 
mils of the solution (1 per cent.). 

It is necessary that sufficient administration of water 
be continued until the causative factor of the anhydremia 
is no longer operative. The initial loss in these infants 
may reach amounts approximating 1000 to 2000 grams. 

The treatment must also be directed to the over- 
coming of any infectious processes which may be pres- 
ent. It is to be rememberd that the severe forms en- 
countered are often seen in infants who have suffered 
from repeated attacks of nutritional disturbances, and 
that in the presence of athrepsia the convalescence must 
necessarily be slow. All laxatives are to be avoided in 
the presence of marked diarrhea, as the bowels empty 
themselves and any further purgation increases the loss 
of salts and water and the tendency to the development 
of an acidosis. 

Opium is indicated when the stools are frequent, large 
and watery, and remain uncontrolled by other methods. 
Paregoric in suitable doses per mouth, or the tincture 
per rectum, may be used with care. 

18 



274 INFANT FEEDING. 

Analeptics. Give a mustard bath in case of collapse. 
Reddening of the skin is a good sign. 

Antipyretics. Use tepid packs, and leave the infant 
undressed. Ice-cap to head is useful, but should not be 
applied directly to the head, because of the thinness of 
the skull in young infants. 

Stimulants. In collapse, warm packs or baths are in- 
dicated. Caffein sodium benzoate, 0.006 Gm. to 0.030 
Gm. (0.1 to 0.5 gr.), four or five times daily; camphor- 
ated oil in 1-mil doses every two hours hypodermically 
if indicated ; epinephrin solution, 0.2 to 0.3 mil (1 to 1000), 
subcutaneously or intravenously. 

Sedati'c'es for Convulsions. Sodium bromide, 0.2 Gm. 
to 0.3 Gm. (3 to 5 gr.), repeated in three to four hours; 
veronal, 0.05 Gm. (1 gr.). Chloral hydrate is best 
avoided. 

An electric fan is a most valuable addition to our 
therapeutic measures in summer. 

Lumbar puncture may be indicated in the presence of 
increased intracranial pressure, and for diagnostic pur- 
poses. 

Diet. Hunger diet should be employed rarely longer 
than twenty-four hours. When infant is stuporous, 
water should be administered by gavage at regular inter- 
vals of about three to four hours. 

In cases of food intoxication, twenty-four hours on a 
hunger diet, with sufficient water, causes striking changes. 
The child looks bright, smiles, and to all appearances 
looks convalescing, notwithstanding a usual loss of 
weight. The stools also become less frequent, and al- 
though small and containing mucus (hunger stools), 
they cause less irritation of the buttocks and little loss 
of water. The improvement is no less striking than 
that seen in the crisis of pneumonia. 

Human Milk. Human milk is. by all means, the best 
food. Feed often, and in small amounts, ten times daily, 
five mils from bottle or spoon. The infant may also be 



ANHYDREMIA. 275 

placed directly at breast for one- or two-minute periods, 
in less severe cases. Increase when the temperature, 
etc., does not react to food, and then not more than 50 
to 100 mils daily increase at first. After several days, 
if the infant shows no evidence of relapse, it is again 
placed unrestrictedly on the breast. If this is done too 
soon, relapses occur. A too prolonged starvation adds 
the danger of inanition. 

A sustaining diet should be reached in eight to ten 
days (70 calories per kilo), after which the child can be 
put on the breast five times daily. Weigh infant be- 
fore and after feeding, if placed at breast. The gain in 
weight is often slow in the stage of repair on human 
milk, due to the low protein and salt content. 

Cozn/s Milk. The feeding of these infants, for whose 
use breast milk is not available, should follow the 
same principles as outlined for the treatment of diarrhea. 
(See page 231.) It must, however, be remembered that 
even greater care is needed because of a tendency to 
recurrence of acute diarrheal attacks. In every case 
where there is a second recurrence of toxic symptoms, 
breast milk is absolutely indicated. These infants do 
best when they are fed with small quantities- — 10 or 15 
mils — repeated at short intervals, with the administration 
of eight or ten feedings daily. This holds true with the 
feedings of albumin milk, as well as with the fat-free 
lactic acid and skim milk plus gruel mixtures. At all 
times the water administration should be held at the 
maximum. For the first few days after the hunger day, 
a food low in fat and sugar should be fed. Even on 
this low diet weight loss usually stops but this should 
not lead to an underestimation of the great danger from 
a too prolonged under-feeding. These infants offer every 
indication for the use of our best judgment. 



CHAPTER VII. 

INFECTION AND NUTRITION. 

The intimate relation between infection and nutrition 
may be made clear by considering the subject under three 
headings : 

1. The susceptibility to infections as influenced by 
previous diet and the state of nutrition. 

2. The course of infections as affected by diet and the 
state of nutrition. 

3. The influence of infection upon nutritional proc- 
esses. 

(a) Parenteral infections. 

(b) Enteral infections. 

1. Susceptibility Influenced by Nutrition. 

The previous diet and the state of nutrition being the 
same, there are marked individual differences in the sus- 
ceptibility to infection. Among the breast-fed infants 
there are on one hand infants who remain free from any 
infection, even under very unfavorable external condi- 
tions, while on the other hand there are breast-fed infants 
who under favorable conditions often contract an infec- 
tion. This points to congenital differences based on the 
difference in the constitution of the individual. As a 
rule, the lowering of immunity is not the only sign of 
inferior constitution in these infants, but they show a 
number of other symptoms of a constitutional anomaly, 
such as exudative and neuropathic diathesis. In this 
group of infants the susceptibility to infection becomes 
even more striking when they are put on artificial feeding, 
and especially when the diet is improper. In infants 
with constitutional anomalies one is justified in thinking 
of an abnormal composition of the tissues and of the 
(276) 



INFECTION AND. NUTRITION. 277 

body fluids, both the latter factors in themselves leading 
to a lowering of immunity. 

The natural immunity of the healthy breast-fed infant 
affords the best example of the importance of the diet 
in the establishment of resistance to infection. 

In the artificially fed infants the increased susceptibil- 
ity to infection is usually based on nutritional disturb- 
ances, which, however, may be so slight as to escape 
recognition. However, when a careful study is made 
of the feeding history the cause can usually be demon- 
strated in a poorly balanced diet, more commonly one 
excessive in carbohydrates and fats, which result in an 
abnormal composition of the tissues (see Nutritional 
Disturbances). Those modes of feeding which cause 
normal tissue chemistry diminish susceptibility, while 
every form of feeding which unfavorably influences 
metabolism increases susceptibility to infection. 

In artificially fed infants these facts offer valuable 
therapeutic suggestions, and should lead one to avoid 
overfeeding as a whole as well as of the individual con- 
stituents of the diet, and the early administration of the 
mixed diet. 

The susceptibility to infection is increased by every 
nutritional disturbance. This applies to the simple and 
seemingly harmless digestive disturbances, as well as to 
the more severe forms. (Athrepsia, anhydremia.) 

2. Course of Infections Influenced by Nutrition. 

The course of the infection is essentially influenced by 
constitution, age, hygienic conditions, mode of feeding, 
and the state of nutrition. The premature and the very 
young react poorly to infections. Gastro-intestinal, pul- 
monary and septic infections of the newborn have usu- 
ally an unfavorable course, especially in the artificially 
fed infants. Infants suffering from constitutional anom- 
alies are less likely to react favorably than normal, 
healthy infants. In all infants suffering from exudative 



278 INFANT FEEDING. 

or neuropathic diathesis even slight infections should be 
given serious consideration. 

Nutritional disturbances have a direct influence on the 
prognosis of all forms of infections. This is more espe- 
cially true of the infections of the respiratory passages, 
in which a simple rhinitis or pharyngitis may readily be 
complicated by pneumonia and severe gastro-intestinal 
complications, but also true of the simple skin infections, 
which may rapidly take a serious course resulting in 
sepsis. 

The institution of a proper diet is of primary impor- 
tance in all cases of infections. 

Feeding with human milk is the treatment of choice. 
If this is not obtainable, and it is necessary to feed arti- 
ficial food mixtures, they must of necessity be well bal- 
anced, and one-sided carbohydrate diets are to be avoided. 
Whenever possible, a mixed diet should be instituted. 

3. Infection Influencing Nutrition. 

Infection may produce any form of nutritional dis- 
turbance, from the slightest forms to the most severe 
forms of athrepsia and anhydremia. For the production 
of nutritional disturbances, infections are to be ranked as 
of equal importance with dietetic errors. 

Although the course of alimentary nutritional disturb- 
ances may be similar to that of nutritional disturbances 
due to infection, still there are important differences that 
must be kept constantly in mind in order to avoid fail- 
ures in the treatment. The following table briefly sum- 
marizes the most important differences between the two 
forms of nutritional disturbances : 

Nutritional Disturbances due to Nutritional Disturbances due to 

Alimentation. Infection. 

History of dietetic errors, espe- Acute disturbances not so 
cially high sugar and fat much dependent on the 

feedings or underfeeding. nature of the diet. 



INFECTION AND NUTRITION. 279 

Nutritional Disturbances due to Nutritional Disturbances due to 

Alimentation. Infection. 

Disintoxication of toxic states Toxic states continue or even 
(fever, nervous symptoms, become worse in spite of 

etc.) by withdrawal of food, withdrawal of food, 

and administration of suffici- 
ent water. 

Improvement in general con- Persistence of diarrhea after 
dition, and especially of diar- similar change of diet, at 

rhea, on correction of the least in a number of cases, 

diet, especially by reduction 
of fat, whey and sugar com- 
ponent part. 

Progressive narrowing of food Spontaneous increase of toler- 

tolerance in untreated cases. ance without special dietetic 

treatment after the infection 

passes over (in majority of 

cases, not always). 

(A) Parenteral Infections. 

Etiology. It has already been pointed out with 
what great frequency infants and children suffering from 
nutritional disturbances are subject to secondary infec- 
tion. The most frequent of these are those of the skin, 
respiratory, gastro-intestinal, and genito-urinary tracts, 
ears and general septic infections. 

In contradistinction to this, infections, such as "colds," 
tonsillitis, pneumonia, otitis, cystitis, pyelitis, which are 
accompanied by lowered food tolerance, are accompanied 
by diarrheas. They are likely to run a more severe course 
than the primary nutritional disturbances. 

Undoubtedly many cases of diarrheal disturbances in 
the course of acute infections are due to an infection of 
the gastro-intestinal tract following the swallowing of 
organisms from the upper respiratory tract, thereby de- 
veloping a secondary enteral infection. 

The common occurrence of the "summer diarrheas" 
leads us to search for a relationship between heat and the 
nutritional disturbances as seen in summer. This rela- 



280 INFANT FEEDING. 

tionship has already been discussed under the chapter on 
Anhydreniia Intoxication. However, it may be well to 
briefly enumerate the factors which are important in the 
causation of these nutritional disturbances. High tem- 
peratures cause systemic depression, and directly influ- 
ence all of the body functions. Less food is required in 
hot weather, and therefore the previous diet may be con- 
sidered excessive in many instances. Bacterial action on 
the milk, and the subsequent production of toxic bodies, 
is a factor of primary importance. An excessive reten- 
tion of heat by overdressing during the summer months 
has been proven to be a contributing factor by McClure 
and Sauer. 1 

A study of the cases of diarrheas in the wards of 
Sarah Morris Hospital by Gerstley and Day during the 
course of two summers showed that most of our intes- 
tinal cases were secondary to parenteral infections, and 
not primary intestinal infections, as described by Ken- 
dall and Day in their investigations of the Boston epi- 
demics. This could in greater part at least be accounted 
for by the fact that all of the milk fed to our infants was 
either pasteurized or boiled, while in the eastern cities 
considerable raw milk was fed. 

Symptoms. By careful clinical observation and ex- 
perimental investigation we know that infection may 
produce the following changes: 

1. Lessening the gain in weight without any acute 
symptoms manifesting in the gastro-intestinal canal dur- 
ing or after the infection. 

2. Loss of weight and changes in the stools cor- 
responding to the acute nutritional disturbances. 

(a) Acute disturbances of the nature of diarrhea 

beginning with the infection and disappear- 
ing after the infection has been overcome. 

(b) Acute disturbances which begin with the infec- 

tion, but remain even after the infection is 



i Sauer : Am. Jour. Dis. of Child., 1915, ix, 490. 



INFECTION AND NUTRITION. 281 

overcome, under certain conditions for weeks 
(chronic intestinal indigestion). 
(c) Grave nutritional disturbances beginning with 
the infection, but soon becoming the most 
prominent factor in the clinical picture, with 
or without toxic symptoms. 

Diagnosis. Anhydremic intoxication is usually easily 
recognized by the nervous symptoms, toxic expression, 
pauseless respiration, and marked drops in the weight 
curve. In intoxication, temporary complete withdrawal 
of food with sufficient water administration in the ab- 
sence of severe infection results in disintoxication. This 
is known as therapeutic dietetic test. In parenteral in- 
fections this is not the case, and starvation only leads to 
further reduction of resisting power, and therefore should 
not be long continued. 

It is necessary to avoid the mistake of overestimating 
the intestinal condition for which in many cases the 
physician is called, and thereby failure to recognize the 
underlying infection, such as "cold," bronchitis, pneu- 
monia, pyelitis, etc., as a fundamental factor. 

Treatment. For treatment practically the most im- 
portant characteristic of nutritional disturbances due to 
infection is the spontaneous rise of food tolerance after 
the cure of the infection. 

The primary infection calls for foremost considera- 
tion, and its treatment must necessarily vary according 
to its nature. The intestinal condition, on the other hand, 
if mild in nature, frequently calls for little treatment in 
these infants, more especially because in the presence of 
fever there is a tendency to reduce the intake of food, 
which in itself is sufficient to correct the intestinal dis- 
turbance. Further, with the improvement of the infec- 
tion the appetite returns, and the infant will demand in- 
creased food. 

Where it is possible to keep up the baby's nutrition by 
the proper administration of food during the course of an 



282 INFANT FEEDING. 

infection, such children may be subject to little or no 
weight loss. In more serious cases the food must be re- 
duced both qualitatively and quantitatively, more espe- 
cially the sugars and the fats. However, in order to 
avoid catastrophes, long-continued underfeeding or star- 
vation must of necessity be avoided, since this treatment, 
causing insufficient nutrition of the body-cells, would de- 
crease the resistance of the infant. Albumin milk, and 
skim and buttermilk mixtures, with small amount of 
sugar are best used. Carbohydrates should be added as 
rapidly as the infant's condition will permit. Prolonged 
carbohydrate starvation is to be avoided, more especially 
in the presence of high temperatures and acidosis. They 
should be increased gradually. In grave nutritional dis^ 
turbances, with sudden losses of weight and toxic sym- 
toms, complete withdrawal of food cannot be avoided. 

In young and weak infants, as previously stated, breast 
milk may be imperative. In older infants, and those less 
severely infected, albumin milk, with 2 or 3 per cent, of 
sugar addition, or buttermilk and skim milk mixtures are 
frequently well taken. In all cases inanition must be 
avoided by keeping the child on a sustaining diet of 70 
calories per kilogram, or an amount above this. 

The type of infants who have been improperly fed, 
more especially those who have been raised on con- 
densed milk or other foods containing a minimum of 
fat and protein, but an excess of carbohydrates, offer 
greater difficulties, because they possess a limited im- 
munity to all forms of infection, beside reacting poorly 
to changes in their diet during illness. They also react 
very poorly to starvation, rapidly passing into a state of 
decomposition. The treatment in these cases should fol- 
low that outlined for milder forms of athrepsia. 

To repeat, under all circumstances food should be re- 
stricted as little as possible. 



INFECTION AND NUTRITION. 



283 



1 
5 

tin . 

a 3 IS J 

.1 

05 «) 

LE 
£g< 

?S a 

-J a 


1 1 

1 a 
5 6 

V 

tr 

<t 
I 

1 1 
a < 

3] z 

Q J 


3 r 


s £ 


8 


O 
0) 

CO 




<x 



z: 






** ( 

< 


/ *° 




' '. 


I s 


8 

3 


O 
0) 

<0 




•z. 






4 \ 


X 

1 «o 




i * 


\ N 

J\ £ 


N 


10 

CO 






CO 




s: 

— Oi 



z 






_^ u 


» | £ 






v ( 1 


8 
8 






CO 




"1 








^ 1 $ 






V £ rig 


8 

m 
*0 

ft 


O 
SO 




— CC 



2 








2 1 £ ^ x 




2 


WU JOIJ ' ST )).:£! g 

. l --. (0 


s 


to 


in 




— oc 


Z 














....(.....API 


g 
a 



to 
to 











E M 






* 03/0 


Hd-l C;;-|()CJS / 


e 


5F 

T 










< N 


"T ~"n -t ' ><■ 






„,..:-. 8 


8 

CD 


to 

CO 










E cv 


.....^:, s , 5 






4. T> g 




CM 


CM 

10 










" }__._. 


" 1 >< 




L-.L.-L,... 


.' & 


N 



Cxi 




of 
"11 






'■' :;_:i. 


1 w 




k { 


..-•:'" 8 



0^ 












7 s I 


/ tt 




* --$=- 





(0 


CO 

CNi 




5& 








CO Qi 




5 >• 

in / -V 


< 


N 
O 


O 




z: 
tOjE'Cr 

5: or 






> 1 


KI.T3NJ i 1^(1- r- 




l °°""^nmm 


SWOUIMS ^ rv) 


O 

§1 

U 


I 8 


K 
1 


11 


c 
S 
£ 




1 lllllll 


1 1 1 1 s 1 1 II 




t A '4 '4 ' 

N N CJ 


°l -I -1 £ * 

£i — — 





284 INFANT FEEDING. 

The two most important symptoms calling for treat- 
ment in the course of parenteral infections are (1) vomit- 
ing and (2) refusal of food. 

If temporary reduction in food does not relieve vomit- 
ing, it may be necessary to resort to gastric lavage which 
is best performed with 1 per cent, sodium bicarbonate 
solution, allowing 2 or 3 ounces of the solution to re- 
main in the stomach, with the administration of slightly 
sweetened tea or cereal waters ad libitum, as retained. 
Prolonged starvation must be avoided. 

We have found chymogen milk fed in small quantities 
at two- to three- hour intervals especially suitable for 
these cases. This is probably due to the fact that the 
casein is precipitated in a flocculent form. 

Refusal of food which is commonly experienced in 
these infants calls for catheter feeding (see chapter on 
Methods of Feeding Premature Infants). 

(B) Enteral Infections. 

Etiology. Besides the alimentary nutritional dis- 
turbances proper, there are in childhood, and especially 
in infancy, numerous diseases that have to be regarded 
as true infections of the digestive canal, due to invasion 
of pathogenic bacteria, or increased and changed activity 
of the bacteria normally present. In many cases infective 
material is introduced by food, and especially by the 
milk, in which the micro-organisms are present, being de- 
rived from the diseased cattle that furnish the milk 
(Streptococcus from inflamed udders, Bacillus coli from 
feces) or bacteria pathogenic for the human may find 
their way into the milk in transportation from the place 
of production to the place of consumption. Besides this, 
water or contaminated foods other than milk may be the 
medium through which infection takes place. 

There are numerous cases of transmission by contact. 
These are most commonly seen in the epidemic appear- 



INFECTION AND NUTRITION. 285 

ance of gastro-enteritis in institutions for small children 
and infants. A small, but typical epidemic is reported 
by Smillie, 1 who had observed it during his study of epi- 
demiology of bacillary dysentery. Four babies developed 
bacillary dysentery in the wards of the hospital, each of 
them having been admitted with quite a different diag- 
nosis, and their stools having been negative on admis- 
sion. Each developed the disease seven to ten days after 
admission, and in no instance did the infant come from 
an infected home or neighborhood. Similar epidemics 
are experienced in all institutions caring for infants, in 
which aseptic nursing is not practiced. 

The environment of the infant, and especially lack of 
proper cleanliness generally, and in preparation of food 
especially, are very important factors, which make the 
enteral infection possible. 

Parenteral infections are often followed by enteral in- 
fections, and this is especially true of infections of the 
respiratory tract which often lead to what has been called 
"bronchoenterocatarrh." 

The most important clinical condition among the en- 
teral infections is inflammation of the intestinal mucosa 
(enteritis), brought about by a variety of bacteria, and 
accompanied by slimy, purulent, and bloody evacuations 
and tenesmus. 

The causative bacteria may be organisms normally 
present in the intestinal tract which in the presence of 
an environment suitable to their abnormal growth, be- 
come pathogenic to the host, or the offending organism 
may be introduced from without through food or by 
contact with infected excreta or other matter. 

The organisms which have been most frequently iso- 
lated from tlie intestinal tract during the more recent 
epidemics are the T>. paratyphosus group, of which the 
alpha and beta types are probably the most frequent of- 



l Smillie: Am. Jour. Dis. Child., 1917, xiii, 337. 



286 INFANT FEEDING. 

fenders in paratyphoid fever in the young. Both of 
these organisms are occasionally found in the intestinal 
contents and feces of children who give no history of 
infection. 

The various types of B. dysenterise have been isolated 
in numerous severe epidemics, in both infants and 
children. 

While this group covers a considerable number of 
bacilli showing minor morphological and cultural dif- 
ferences, they may, however, be divided into two main 
groups, the division being based on the difference in their 
reaction with litmus mannite. The first group is known 
as the "true Shiga," or "alkaline type"; the second as 
the "acid type," which includes the organisms which have 
most frequently been found in the diarrheal diseases of 
infants and children in the United States. This second 
group includes the Flexner-Harris, the "Y" type of Hiss 
and Russell, and the Strong subvarieties. The "Shiga" 
type has been found m some cases alone and even less 
frequently it has been isolated in cases in which the 
"acid" types were present. Both of these latter findings 
have, however, been the exception in the dysenteries of 
children. 

B. typhosus, while not an infrequent cause of severe 
infectious diarrhea in infancy has only rarely been iden- 
tified as the specific organism in generalized epidemics. 

B. coli may become so abundant and virulent as to pro- 
duce severe types of enteritis. Streptococci have been 
reported repeatedly as the predominating organism in 
isolated epidemics of severe types associated with deep 
intestinal lesions. 

The role of B. aerogenes capsulatus (gas bacillus of 
Welch) as a specific factor in epidemics is still in dis- 
pute. It has been isolated in large numbers and was a 
constant finding in several epidemics. It has a profound 
influence in the reaction to- diet in such cases and is re- 



INFECTION AND NUTRITION. 287 

sponsible to a large degree for the character of the stools 
when present in large numbers. 

B. pyocyaneus, B. lactis aerogenes and the proteus 
group as specific factors are open to question and it is 
more likely that they were accompanying rather than 
specific in reported epidemics. 

Kendall and Day, making a careful study of the epi- 
demics of summer diarrhea in Boston, found that during 
the year 1910 the epidemic was mainly due to dysentery 
bacilli, fully 75 per cent, of 52 cases being due to these 
organisms. Streptococci were also present in about 60 
per cent, of the dysentery cases, probably as secondary or 
terminal invaders. The summer of 1911 was noteworthy 
as a "streptococcus" year; 54 per cent, of 146 cases 
studied harbored large numbers of these organisms. The 
year of 1912 was a "gas bacillus" year, these organisms 
appearing in unusually large numbers in 39 per cent, of 
135 cases examined. Each of the above types was found 
each year, but the striking feature is the shifting of the 
dominant organism from year to year. Kendall con- 
cludes that, bacteriologically considered, these cases are 
of varied etiology, caused by organisms of very unlike 
characteristics. 

In contrast to this, studies of the summer diarrheas 
at the Sarah Morris Hospital for Children (Chicago) 
during the course of two summers, showed that most of 
them were secondary to parenteral infections (see page 
280). Day worked both in Boston and Chicago cases, 
and therefore the error could not have been one of 
technic. The difference was probably due to use of 
boiled milk in Chicago, and unboiled milk in the East. 
The infection in most cases probably being due to organ- 
isms ingested from the upper respiratory tract. 

Pathology. To the invasion of pathogenic bacteria 
the digestive canal reacts by inflammation of the intes- 
tines (enteritis). The large intestine is always more 
affected, while in the small intestine the pathological 



288 INFANT FEEDING. 

process, as a rule, is limited to its lower portion. How- 
ever, in cases secondary to infections of the nose and 
throat, even the gastric mucosa may be involved. Mes- 
enteric lymph-glands are swollen. In some cases the 
bacteria invade the deeper organs also, and may be cul- 
tivated from the spleen and the gall-bladder. Liver and 
kidneys show degenerative changes in severe cases, 
probably due to the action of toxins. Occasionally 
other organs may secondarily become affected (otitis, 
pneumonia). 

The inflammation of the intestines may reach any de- 
gree of severity, and is dependent to some extent at least 
upon the causative organism, being, as a rule, most 
marked in cases in which dysentery, typhoid, and strep- 
tococcic organisms are excitants of the pathological 
process. 

It may be a hyperemia, and swelling associated with 
exudation of excessive amount of mucus and occasion- 
ally of blood, producing a picture of catarrhal gastro- 
enteritis marked by mucus, mucopurulent, and occasion- 
ally also slightly bloody diarrheal stools. These cases 
are caused by a variety of bacteria, and they are often 
secondary to infections of the respiratory tract, the same 
micro-organisms being causative in both instances. We 
have frequently seen such a clinical picture associated 
with severe vomiting, and a secondary acidosis following 
in the course of a streptococcus sore throat. 

Intense swelling of Peyer's patches in the small intes- 
tine is seen in typhoid infection. Sloughing and ulcer 
formation is far less frequent than in adults. 

In paratyphoid infections, while infiltration of Peyer's 
patches and solitary follicles are usually present, deep 
ulceration is lacking, as a rule. 

In infection with dysentery bacilli, the large intestine is 
especially affected, being the seat of sero-hemorrhagic 
and hemorrhagico-purulent inflammation, with marked 



INFECTION AND NUTRITION. 289 

tendency to formation of ulcers throughout a large part 
of the large intestine, and less frequently in the course 
of the ileum. 

Again, we may see marked intestinal pathology, as 
evidenced by deep-seated ulcerations and infiltrations of 
mucosa and secondary inflammation of the submucous 
and muscular layer of the intestinal wall, which condition 
is usually spoken of as ulcerative follicular colitis, and 
this may be complicated by formation of a pseudomem- 
brane in various areas throughout the large intestine, 
which condition has been described as a membranous 
colitis. In many of these cases it is difficult to determine 
the exact bacteriological factor, because of the presence 
of secondary organisms. Most of these cases are either 
subacute or seen as secondary involvement in infants who 
have suffered from repeated nutritional disturbances. 

On the whole, in those cases of inflammation of the 
intestinal tract due to bacterial infection and presenting 
serious pathological changes, the most marked changes 
are found in the lower three feet of the small intestine 
and in the large intestine. While there is very frequently 
a disparity between the severity of the clinical symp- 
toms and the pathological changes seen post-mortem in 
that not infrequently severe symptoms are associated 
with little pathology, on the other hand marked patho- 
logical changes are almost invariably associated with a 
severe clinical picture. 

Symptoms. The symptoms vary with the individ- 
ual excitant of the disease, and thus also to a certain ex- 
tent with the pathology, but, in general, the symptoms 
are so variable and with very few exceptions so little 
characteristic for the particular excitant that the etio- 
logical and pathological grouping of clinical pictures is 
impractical. It seems much better to differentiate the 
various forms from the clinical point of view. 

Diarrhea with slimy or purulent evacuations, often 
with blood, accompanied by abdominal pain, tenesmus 

19 



290 INFANT FEEDING. 

and fever, are the most characteristic and the most con- 
stant symptoms of enteral infections. 

The onset and progress of enteral infections, as a rule, 
are sudden and rapid, and in this way they markedly dif- 
fer from alimentary nutritional disturbances in which 
prodromes consisting of milder symptoms are often pres- 
ent, and the progress is gradual. In enteral infections the 
stormy course may result in rapid production of a very 
severe picture of general prostration, and even an early 
fatal outcome. 

Diarrhea is so constant that these cases have been 
designated as "infectious diarrhea," and yet it should be 
remembered that typhoid and paratyphoid infections in 
young individuals may be associated with any degree of 
constipation early in the disease. The stools are, as a 
rule, frequent, often one every hour, and there are also 
cases in which the bowels seem to move almost contin- 
uously. The number of stools varies also, according to 
the seat of the most severe inflammation, and they are 
more numerous when the large intestine is chiefly 
affected. 

Loss of weight, often sudden and marked, is always 
present, and is due to many evacuations, and also to ac- 
companying nutritional disturbance. 

Stools. The macroscopical appearance of individual 
stools varies not only with the etiological factor, but is 
also dependent to a great extent upon the reaction to 
food, and upon the intestinal pathology, and is therefore 
of little value in the etiological diagnosis of enteral in- 
fections. The size of the stools is indirectly propor- 
tional to their number. In the beginning they appear to 
be of normal composition, but sooner or later they are 
composed chiefly of mucus and blood, and occasionally 
pus may be seen, even by the unaided eye. Portions of 
the intestinal mucous membrane are seen in severe cases 
at the time of sloughing and ulceration. The odor of 
the stool varies with its composition, and thus with the 



INFECTION AND NUTRITION. 291 

progress of the disease. In the beginning the odor is that 
of the normal stool ; later stools, composed of mucus and 
blood, are almost odorless ; and those containing large 
quantities of sloughs have often a putrefactive odor. 
The reaction of the stools varies also with their composi- 
tion, being mostly alkaline. In exceptional cases the 
stools may not be considerably increased in number, and 
may contain neither mucus, nor blood, nor pus. 

Abdominal pain and tenesmus, due to irritation by the 
bacteria and their products, and also due to the abnormal 
intestinal contents, and to increased peristalsis, and some- 
times to distention, appear very early in the disease, often 
being the first symptoms. Although being severe usu- 
ally, they vary from a slight discomfort to excruciating 
pain, which keeps the child constantly awake, and, caus- 
ing exhaustion, adds to the severity of the case. Ab- 
dominal distention is intermittent, the abdomen being 
usually sunken. Abdominal tenderness is not frequent. 
Anorexia is almost always present, while vomiting is 
more commonly seen early. 

Fever is always present in enteral infections, and varies 
with the severity of the infection and the pathology. 
More often it-is not extreme after the first exacerbations. 
It persists throughout the disease. 

Leucocytosis and oliguria are usually present. 

Enteral infections are always associated with nutri- 
tional disturbances, since the infection affects an organ 
chiefly concerned in nutritional processes. And nutri- 
tional disturbances, again, produce symptoms of their 
own. 

The course of enteral infections varies considerably, 
being dependent chiefly upon the nature of the organism 
and the stage of nutritional disturbance that develops, 
and also on the nature of complications. Some cases 
may be so mild as to resemble subacute dyspepsia, and 
only inability to influence the fever by the diet may point 
to their true nature. On the other hand, however, severe 



292 INFANT FEEDING. 

toxic conditions occur, being due either to sepsis or to a 
nutritional disturbance which develops secondarily to in- 
fection. The duration of the disease varies from a few 
days to several weeks. 

Complications. The great danger of the infections 
of the gastro-intestinal tract lies in their tendency to 
complications, at the head of which stand nephritis and 
pneumonia. Other complications are cysto-pyelitis and 
various pyodermatoses, and other pus infections and gen- 
eral pyemia or septicemia, which start either from the 
skin or from the diseased intestines. 

More important than this is the association of infec- 
tious diseases of the intestines with secondary nutritional 
disturbances. It is easy to understand that in severely 
diseased intestines the normal digestion of food is made 
especially difficult, and thus acid decomposition easily 
occurs, which in turn leads to dyspepsia, and in the wake 
of these even the alimentary decomposition and alimen- 
tary intoxication may be implanted upon the original dis- 
ease. The inanition caused by the too prolonged feeding 
with an unbalanced diet, such as cereal waters (flour in- 
juries. Mehlnahrschaden) may in some cases reach dis- 
astrous gravity. There can be no doubt that the majority 
of the cases resulting in athrepsia are not due to the in- 
fection alone, but also to the inanition and other forms 
of secondary nutritional disturbances, and it is probable 
that even a part of the severe ulcerative forms and vari- 
ous complications develop on the same foundation. The 
underfeeding alone gradually decreases the general power 
of resistance of the body; it weakens also the antibac- 
terial functions, and thus the local or general infection 
may spread unimpeded. 

Diagnosis. In making a diagnosis it is necessary to 
differentiate the enteral infections not only from (1) 
alimentary nutritional disturbances, but also from (2) 
nutritional disturbances caused by parenteral infections. 
(3) Diagnosis of the causative organism or group of 



INFECTION AND NUTRITION. 293 

organisms is also of great importance for the treatment. 
(4) Enteral infections are always complicated by nutri- 
tional disturbances, and it is of great importance to recog- 
nize the degree (simple infectious diarrhea, anhydremia 
and intoxication) to which the infant is affected. 

In practice it is often difficult to differentiate clinically 
the gastro-intestinal infection from other forms of ali- 
mentary disturbances, because neither bloody and puru- 
lent stools nor the finding of pathogenic bacteria in the 
stools in itself is sufficient for the diagnosis of enteral 
infection, except possibly in the presence of typhoid, 
paratyphoid, and dysentery bacilli. 

An easily applicable method of differentiation is the 
test for the reaction to starvation and feeding. Fever 
continuing after withdrawal of food speaks for infec- 
tious etiology. Inability to influence the symptoms by 
diet is to be interpreted in the same sense. 

History is of considerable importance in making a dif- 
ferential diagnosis. The acute infectious diarrhea starts 
usually suddenly in a previously well baby, and pros- 
trates it at once, while the alimentary nutritional disturb- 
ance comes on gradually. In the latter we get a history 
of improper feeding, of previous nutritional disturbance, 
of parenteral infection. It is more gradually progressive. 

The differentiation between the enteral and the paren- 
teral infections is somewhat more difficult, and is to be 
made chiefly by exclusion of the parenteral infection by 
careful physical examination of the patient. The bloody, 
purulent stools are usually absent in the cases secondary 
to parenteral infection. 

The diagnosis of the causative organism is to be made 
by proper bacteriological examination and culture of the 
stools, and by agglutination reaction. Kendall states that 
frequently it is very difficult to determine the organism 
causing the disease, and therefore he has attempted to 
classify the causative organisms into two groups with a 



294 INFANT FEEDING. 

special reference to treatment. 1 He divides them into 
two large groups: (1) the various forms of dysentery 
bacillus and all other organisms except the gas bacillus; 
(2) the gas bacillus and the allied organisms. 

While this classification of organisms for treatment 
theoretically offered great advantages, in our own clinical 
work we have not experienced the encouraging clinical 
results which might be expected, and have instituted a 
general course of treatment based more directly on the 
severity of the infection and the symptoms as presented 
by the cases at hand. 

Stool cultures should be made according to the method 
of Kendall for gas bacillus. This method is so simple 
that it may be performed even outside of a well equipped 
laboratory. A small portion of the stool is added to a 
test-tube of litmus milk. The test-tube is then heated on 
the water-bath, and left in the boiling water for three min- 
utes. By this procedure all the bacteria in the stool that 
are not in the stage of spores, are killed, and the bacteria 
develop unrestrained from the spores subsequently. Gas 
bacilli, being sporogenous, survive the boiling. The test- 
tube is finally incubated at a body temperature for about 
twenty-four hours. In the presence of large numbers of 
gas bacilli a large part of the casein is dissolved, but the 
remaining casein is filled with holes, as if shot to pieces, 
and somewhat pinkish in color. The odor reminds one 
of rancid butter, and is due to formation of butyric acid. 
The true reaction may be easily differentiated from the 
pseudoreactions, in which some liquefaction of casein 
also occurs, but in which the shotted appearance of the 
residual casein and the odor of butyric acid are absent. 

Differential studies for typhoid, paratyphoid, and dys- 
entery bacilli on endomedium and Russell's double sugar 
medium, and by further fermentation tests, are indicated 
in the presence of epidemic or severe endemic cases. 



1 Kendall and Smith : Boston Mod. and Surg. Jour., 1910, clxiii 
578. 



INFECTION AND NUTRITION. 295 

While agglutination reactions are uncertain in very 
young infants, because of the slight tendency to the for- 
mation of agglutinins, in older infants and children they 
are of very considerable value, as demonstrated by the 
study of agglutinins by the author at Cook County and 
Sarah Morris Hospitals during the year 1914. In a series 
of 30 cases studied in which agglutinations were made for 
typhoid, paratyphoid (alpha, beta, and Morgan), dysen- 
tery (Shiga and Flexner), and colon bacilli, the follow- 
ing organisms were demonstrated : typhoid, 2 ; paraty- 
phoid (Morgan), 1; dysentery, 2. All of these cases 
yielded the respective organisms in large numbers from 
their stool cultures. This method of examination is 
easily carried out in a well regulated laboratory, and is 
worthy of further consideration in the presence of an 
epidemic of enteritis or isolated cases of severe enteral 
infection. 

The stage of the nutritional disturbance is best diag- 
nosed by the reaction of the temperature and toxic symp- 
toms to complete withdrawal of food, and presence or 
absence of paradoxical reaction. Starvation in the pres- 
ence of infection must always be recognized as a danger- 
ous procedure. 

Prognosis. The prognosis of enteritis is, in general 
favorable. Death is almost always due to complications 
with septic affections or nutritional disturbances. 

The mortality rate varies greatly in different epidemics. 
The same organism may in one year cause a widespread 
mild epidemic; at another it may be associated with a 
high mortality. Epidemics among institutional infants 
must always be given serious consideration. 

In infants and younger children the prognosis depends 
essentially upon the ability of the physician to apply the 
proper dietetic methods suitable for the particular case. 
If he succeeds — and this is at present possible in very 
many cases — avoiding grave secondary nutritional dis- 
turbances, then he will be able to save a surprisingly 



296 INFANT FEEDING. 

large percentage of cases; if he is unsuccessful in this 
direction, then his results will be unsatisfactory. 

Treatment. Prophylaxis. In the etiology of enteral 
infections several facts based on bacteriological studies 
and clinical observations stand out so prominently that 
the methods of prophylaxis must be based upon them in 
order to be successful. 

1. In the great majority of cases the infection is intro- 
duced with the food. Whenever intestinal infection oc- 
curs in a breast-fed infant in a private home, the first 
thought should be that the infant was probably getting 
other food besides mother's milk, and only after exclu- 
sion of this probability should the causes be looked for 
in the environment of the infant, especially the cleanli- 
ness of the mother and the general hygiene of the home. 
In artificially fed infants the prophylaxis of enteral in- 
fections consists of obtaining pure and wholesome milk, 
keeping it clean, boiling when in doubt, and careful prep- 
aration of proper mixtures. 

2. In many cases the infection occurs by contact, espe- 
cially in institutions. Isolation of severe cases of intes- 
tinal infection is therefore essential, and isolation of all 
suspicious cases advisable, especially in institutions. 

3. The environment of the infant, and especially lack 
of proper cleanliness generally, and in preparation of 
foods especially, are very frequently predisposing and 
accessory factors. The methods instituted to counteract 
these influences must, of course, be adapted to the in- 
dividual case. 

4. Parenteral infections are often followed by enteral 
infections. Proper treatment of parenteral infection, 
special attention to the diet and general hygiene, are the 
keynote of prophylaxis in these cases, the possibility of 
secondary enteral infection being constantly kept in mind. 

5. Alimentary nutritional disturbances increase suscep- 
tibility to any form of infection, and especially to enteral 
infection, and the prophylaxis of secondary enteral in- 



INFECTION AND NUTRITION. 297 

fections coincides practically with the prevention and 
proper treatment of these nutritional disturbances. (See 
also "Susceptibility Influenced by Nutrition," p. 276.) 

Initial. . The object of the initial treatment is to de- 
crease as much as possible the number of bacteria present 
in the intestine, and the removal of irritating intestinal 
contents. Intestinal disinfection by drugs is impossible; 
and the cleansing of the intestines by the administration 
of large quantities of inert fluids, enemata, and possibly 
an initial laxative, is the best that can be done in this 
direction. 

Castor oil, which is usually taken plain without any 
difficulty by infants, in doses of 1 to 2 teaspoonfuls, is 
the best laxative for these cases, since it causes very 
little intestinal irritation. Only in cases where it is 
vomited, we should resort to magma magnesias (]/ 2 to 4 
teaspoonfuls), or to calomel, 0.06 gram (1 gr.), given 
in doses of 0.015 gram (% gr.) every half an hour until 
two to four doses are given. Calomel should always be 
administered with caution and is best used with sodium 
bicarbonate. The calomel can be followed to advantage 
with 1 or 2 teaspoonfuls of magma magnesias. 

An enema of physiological saline (1 teaspoonful of 
salt to 1 pint of water) is useful. 

All food should be stopped for from six to twelve 
hours. It is not desirable, as a rule, to withhold the food 
longer than this time. 

Water should be given freely during the starvation 
period. The water may be given either warm or cool, or in 
the form of weak tea. Saccharin may be used to sweeten 
it, using 0.01 gram ( % gr. ) of saccharin to 8 ounces 
of water, if desired. In presence of marked anorexia 
or refusal of fluid on the part of the infant, the water or 
tea must be administered by catheter. In persistent 
vomiting, frequent resort to gastric lavage with 1 per 
cent, sodium bicarbonate solution will relieve vomiting, 
and be followed by retention of fluids given by mouth. 



298 INFANT FEEDING. 

When the latter does not relieve the vomiting, physiologi- 
cal saline solution or Ringer's solution must be given 
either by rectum or subcutaneously. 

Local and Medicinal Treatment. Abdominal pain and 
tenesmus are often so severe that they require a special 
treatment. Moist heat in the form of compresses, hot 
water bottles or electric pads should be given preference, 
and only in cases in which they do not afford relief 
should recourse be had to opium or morphine. Tincture 
of opium in doses of 3 to 5 drops may be given in 10 per 
cent, starch solution by the rectum, or 0.01 to 0.03 gram 
(% to Y2, gr.) of pulvis ipecacuanha? et opii (Dover's 
powder) (beware of vomiting), or 5 to 20 drops of 
tinctura opii camphorata (paregoric) by mouth. In some 
cases 1 or 2 doses of morphine may be preferable, since 
it decreases the peristalsis less markedly than opium ; the 
dangers of its administration to infants must be remem- 
bered, and the dosage must be minimal (0.0003 to 0.001 
gram— ^00 to % gr.). Atropin— % 500 to % 00 gr. and 
epinephrin in 1 :1000 solution, 1 to 5 minims, may be in- 
dicated in the presence of marked atony of the intestinal 
tract. Argyrol in 6 grain doses, administered as a 10 
per cent, solution, may have a beneficial influence. (See 
page 236.) 

Stimulants are indicated in some cases of extreme ex- 
haustion, and in cases of sudden collapse. In the ab- 
sence of hyperexcitability of the nervous system, strych- 
nin is the most generally useful stimulant. It is given 
in doses of 0.00005 to 0.0003 gram (i/ 1000 to y 200 gr.). 
Caffein in the form of caffein sodium benzoate, or 
citrated caffein, are of value, and is given in doses of 
0.01 to 0.03 gram (% to y 2 gr.). Camphor 0.05 to 0.10 
gram (1 to 2 gr.) dissolved in sterile oil may be injected 
subcutaneously in emergency, to be repeated as indicated. 

Special symptoms and conditions arising during the 
course of the disease, as high fever, excessive vomit- 
ing, symptoms of nervous excitation, or extreme depres- 



INFECTION AND NUTRITION. 299 

sion, are to be treated as detailed under Anhydremia 
page 259). 

Injections of silver nitrate are of value in some cases 
where blood and pus persist in the stool even after the 
subsidence of acute symptoms, and especially in dysen- 
tery. Before an injection is given, the colon should be 
irrigated first with sterile water (not saline). One 
per cent, silver nitrate solution is then injected in a suit- 
able quantity. If it causes any pain or irritation, it 
should be washed out with saline solution. It should not 
be repeated more often than once a day, and if three 
injections do not result in marked improvement it is 
better to discontinue them. 

Dietetic Treatment. Hitman Milk. The ideal treat- 
ment for all cases of intestinal infections is by feeding 
with human milk, and whenever obtainable, more es- 
pecially in the severe types it is by all means the diet of 
choice. Feeding with human milk, especially in young 
infants, produces very good results, because it retards 
the complicating nutritional disturbance, and thus favors 
healing. 

Artificial Feeding. From the- great number of food 
mixtures that have been advised for enteral infections, 
we may judge as to the difficulty of feeding in such cases. 
It is probable that success may be obtained with any 
feeding which prevents the aggravation of nutritional 
disturbance, and favorably influences the nutritional dis- 
turbance which may exist. Feeding with albumin milk, 
skim and buttermilk, and cereal mixtures and whey- 
cereal mixture (Frank) offer the least risk. 

Prolonged starvation by insufficient diet or by refusal 
on the part of the infant to take the prescribed diet is 
ahvays disastrous, and must be avoided. After six, or 
at the most twelve, hours on the tea diet the infant is 
placed on cereal water (barley, rice, or flour ball), using 
1 tablespoonful of the flour to a pint of water in young 
infants, and 2 tablespoonfuls to the pint of water in 



300 INFANT FEEDING. 

infants over 1 year. After twelve to twenty-four hours 
on the above diet an ounce of young chicken, veal or 
lamb broth can be added to the above cereal waters, 
seasoning with a small amount of salt. If the child will 
take the food, it may be given in the same quantities to 
which the child has been accustomed, or smaller quanti- 
ties at more frequent intervals. 

By far the best results obtained in our private and hos- 
pital work have been by instituting feeding with the al- 
bumin milk 1 of Finkelstein after the first twenty-four 
hours on an inert diet. The value of the albumin milk 
may be explained by the fact that it is easily digestible, 
containing moderate quantities of fat and sugar and finely 
divided casein, which is easily digested in this form. The 
rules to be followed in the feeding with albumin milk 
are described under Diarrheal Disturbances. (Page 
234.) This diet is also to be recommended in home prac- 
tice, wherever it is possible to obtain it, either from a 
neighboring hospital or by instruction of the nurse or of 
the mother. Feeding with albumin milk should be be- 
gun after twenty-four hours on the tea and cereal water 
diet. Sufficient quantity of inert fluid, either in the form 
of water, tea, or cereal water should be given with or 
between the small feedings of albumin milk. One of the 
gravest dangers in the severe infections is that the in- 
fants are likely to take too little rather than too large 
quantities, and are especially prone to vomit when the 
food is forced upon them. 

Boiled skim buttermilk or skim milk with starch or 
flour ball added (1 tablespoonful to the pint) may be 
used as substitute, if albumin milk cannot be obtained. 
They are, however, not so efficacious. They should be 
fed in small quantities, as recommended for albumin 
milk. 



1 Dilutions of the dry forms in which it is obtainable on the 
market will answer. (See Appendix.) 



INFECTION AND NUTRITION. 301 

Chymogen milk (either made from the whole milk, or 
in severe types from skim milk), either diluted or in 
small quantities, if given full strength, is frequently re- 
tained when- the stomach is very irritable, and where the 
child objects to the less palatable albumin milk and but- 
termilk mixtures. 

For further treatment see Diarrheal Disturbances. 

"The whey-cereal mixture therapy of Frank deserves 
mention. It is administered as follows : 

1st day: Initial starvation period on tea for not longer 
than twelve hours. 

2d day : Feed five times 50 grams whey and 50 grams 
cereal gruel prepared from crushed grain. 

3d day: Increase to 60 grams whey and 60 grams 
cereal gruel. 

4th day: 75 grams whey and 75 grams gruel. 

5th to 8th day: Not later than on the fifth to eighth 
day of treatment replace a tablespoonful of whey by 
tablespoonful of milk. Increases of milk to be guided by 
the infant's progress and needs. 

9th to 11th day: Increase the addition of milk 
gradually. 

12th to 14th day : Even in the grave case 400 grams of 
milk and 400 grams of cereal gruels and 200 grams of 
meat broth must be given, and not later than in this time 
the broth is to be prepared with strained rice or farina. 
In infants over 1 year, beginning with the tenth day, 
finely scraped beef may be added." 

A careful record should be kept of the exact amount 
of milk and other fluids taken in each twenty-four hours, 
and, where possible, the child should be weighed daily to 
ascertain the loss in weight. 

The dietetic therapy has never such a prompt result as 
in alimentary nutritional disturbances. Even in favor- 
able cases the disease (purulent and bloody stools, fever) 
continues for one week; in unfavorable cases, several 
weeks. Strict adherence to the food regime once insti- 



302 INFANT FEEDING. 

tuted is desirable. In these cases no greater mistake 
could be made than to change diet with introduction of 
repeated hunger days, or to allow the infant to remain on 
small quantities of food. Thus, an infant suffering from 
infection succumbs often not to the infection, nor to the 
nutritional disturbance, but to inanition. 

Diet in Convalescence. The problem of nutrition 
offers great difficulties, even after the subsidence of the 
fever, and following the improvement in the number and 
character of the stools, as it is frequently necessary to 
keep the infant on a restricted diet for from one to three 
weeks. Only rarely it is possible to feed sufficient caloric 
units for the maintenance of weight during the first and 
the second weeks of the illness. Where possible, the 
albumin milk, buttermilk, skim milk, and chymogen milk 
and cereal gruels should be gradually increased, and 
these increases in quantity should be maintained even in 
the presence of moderately bad stools if vomiting is ab- 
sent, unless one becomes convinced that one or the other 
of the food elements is absolutely detrimental to the 
infant's welfare. 

It is our desire to impress that possibly the gravest dan- 
ger to the infant during the period of convalescence is 
that of underfeeding. Upon the return to milk mixture 
small quantities of boiled milk, low in fat (albumin milk, 
buttermilk, skim milk) should at first be used. This may 
be accomplished by adding it to the cereal gruels. Dur- 
ing this stage beef juice broths, egg albumin, coddled 
egg (prepared as for typhoid fever patients), zwieback 
crumbs, pap, custards, and junket may be added. Under 
conditions where ideal milk and milk preparations can- 
not be obtained, we have found that not infrequently the 
better brands of evaporated milk, as obtained on the open 
market, are useful, when properly diluted. The use of 
condensed milk should be avoided. 

The obstinate constipation which is sometimes seen 
during convalescence should be treated with the utmost 



INFECTION AND NUTRITION. 303 

conservatism along the lines as laid down for constipa- 
tion. The infant should have at least one evacuation of 
the bowels daily. A saline enema is usually sufficient to 
produce this result. 



PART V. 

Rickets (Rachitis). 



Rickets is a chronic general disorder of nutrition. 
The predisposing etiological factors have been, to a con- 
siderable degree, clarified by recent investigations and 
it is to be expected that from the clinical and technical 
studies now in progress, considerable new knowledge as 
to the exact etiology will be forthcoming in the near 
future. 

The pathological changes, while most evident in the 
osseous structure, may involve all of the body tissues 
and organs, including the nervous, muscular, respiratory 
and circulatory systems, the blood-making organs, liver, 
skin, hair, teeth and nails. 

Its clinical manifestations are most commonly evi- 
denced in the second half of the first year in the full 
term infant. In the premature and congenitally diseased 
infants, and not infrequently in other infants, it can be 
diagnosed even before the third month of life. Radio- 
graphic diagnosis is usually possible before clinical signs 
are sufficiently manifest to warrant a conclusive diag- 
nosis. However, in the first stages they are frequently 
overlooked because of the permeability of the rarified 
structure to the roentgen rays. The bones may be but 
slightly increased in density over the surrounding soft 
tissues. The diagnosis is usually made upon the pathog- 
nomonic bone lesions of the second and third stages. 
The bone lesions of the first stage are less frequently 
recognized but are of even greater importance for the 
adoption of proper hygienic, dietetic, and medicinal thera- 
peutics for the prevention of permanent tissue changes 
(304) 



RICKETS. 305 

and deformities. The treatment demands a general 
knowledge of all of the possible underlying etiological 
factors, the associated general systemic as well as the 
bone changes and the possible progressive bone deformi- 
ties which may develop even after the predisposing fac- 
tors have been removed and the acute process arrested. 

Etiology. Most of the theories as to the exciting 
causes can be grouped into four classes, namely: die- 
tetic, hygienic, infectious, and endocrinous. 

While this disease is in all probability primarily a diet- 
etic disorder, in most cases in the human, improper 
hygienic conditions and infections may hasten the de- 
velopment of the pathognomonic bone and systemic 
changes and precipitate the clinical manifestations, more 
especially of the secondary complications. 

Rickets is the most common chronic disorder of in- 
fants living in the Temperate Zone. Schmorl, 1 in a 
series of histologic studies, found that 90 per cent, of 
the children in his Dresden clinic, dying before the age 
of 4 years and examined at autopsy, had rickets, either 
manifest or latent. Dick 2 found that 80 per cent, of 
the children examined in the London county schools had 
the disease or had suffered from it previously. Kas- 
sowitz 3 calculated that 90 per cent, of the children in 
the out-patient department of his Vienna clinic were 
rachitic. Epstein 4 gives about the same figures for 
Prague, and Kissel 5 for Moscow. Engel 6 states that 
in Germany, during the late war, all young children were 
affected to some degree. He attributes this especially 
to the lack of fresh milk and fats during - the war. 



1 Schmorl : Ergebnisse dcr Inneren Medizin u. Kinderheilkunde, 
1909, p. 403. 

2 Dick, L. : Proc. of Roy. Soc. Med., 1915— Brit. Jour. Dis. of 
Children, 13—332, Nov. 16. 

3 Kassowitz : Modern Clinical Medicine — Dis. of Children, Julius 
Springer, Berlin, 1910, p. 239. 

4 . 5 Epstein and Kissel : Ibid, p. 239. 
c Engel: Lancet 1, 188, Jan. 24, 1920. 

20 



306 INFAXT FEEDING. 

E. J. Huenekens 1 reports that 39 per cent, of the in- 
fants in his Minneapolis Welfare Clinic showed definite 
clinical signs of the disease. Hess 2 reports 90 per cent, 
of the infants in a New York City infants' asylum as 
showing evidence of rickets. 

It must be remembered that the figures above quoted 
are taken from patients among the poorer classes. 
Abroad and in this country out-patients are also com- 
posed largely of a class, many of whom would be sub- 
jects of improper artificial feeding or as disastrous 
underfeeding, or improperly balanced diet and overwork 
in the lactating mother. These figures must be neces- 
sarily high when compared with those of the better 
classes, and more especially children from rural districts, 
who live in the open and receive an abundance of fresh 
milk and green vegetables. 

Interesting and important is the recognition of the 
effect on the development of rickets in the offspring 
due to the changes of climate, environment and diet in 
the parent. 

In the United States almost all the negro infants in 
northern cities have rickets, whether bottle- or breast- 
fed, although it is more frequently of a severer type in 
the artificially fed. It is far less frequent in negroes 
of the southern states and uncommon in negroes of Cuba 
and the West Indies. 3 The condition is also very preva- 
lent among Italians in the United States, although in- 
frequently seen in the rural districts of Italy. It occurs 
more commonly and severely among the poorer of these 
individuals. 

Hess and Unger found that the diets of lactating 
northern negro mothers were deficient in fresh vege- 
tables and fruit, and contained an excess of carbo- 
hydrates, the diets, therefore, being poor in calcium, phos- 



i Huenekens, E. J.: Jour. Lancet. 37, 804, Dec. 15, 1917. 

2 Hess, A.: Jour. Am. Med. Assoc., 76—698, March 12. 1921. 

3 Hess and Unger : Jour. Am. Med. Assoc., 70—900, 1918. 



RICKETS. 307 

phate and the vitamines. It must be remembered that 
the human body in all probability cannot synthesize the 
vitamines but must depend upon the amount eaten for 
that to be contained in breast milk. The mother's diet 
thereby directly influences the amount fed to the suck- 
lings. The same factors, in all probability, play an im- 
portant role among the Italian immigrants. Both of 
these classes of individuals also show a tendency to nurse 
their offspring beyond the point of their physical and 
physiological capacity. 

Neve 1 called attention to the fact that rickets is ex- 
ceedingly rare in parts of India where infants live under 
the worst conditions of hygiene and diet, but where sun- 
light, to which they are almost constantly exposed, 
abounds. Similar observations have been made in the 
Hebrides, off the coast of Scotland, where many infants 
live in dark, damp houses during their first year, but in 
whom rickets is rare, due to the fact that the mothers 
live largely on fish, especially codfish livers, and milk 
products and moderate amounts of vegetables. On the 
mainland of Scotland, where the diet of the mothers is 
largely made up of milled cereals, muscle meat, and 
potatoes, rickets is very prevalent although the hygienic 
surroundings are much better. 

Season. It is more active in the winter and spring 
months and in this peculiarity, hygiene, lack of exposure 
to sunlight, insufficiency of fresh foods in the mother's 
or cow's diets, and intercurrent infections may one and 
all be contributory factors. 

The age of onset varies considerably. In the mature 
infant the symptoms usually manifest themselves be- 
tween the sixth and eighteenth months. Some observers 
describe as congenital rickets, a condition involving the 
osseous system which develops intra-uterine, presenting 
similar pathological findings at birth. There has been a 
great deal of content inn as to the exact nature of these 

iNeve, E. F. : Brit. M. J., Vol. 1, 518, 1919. 



308 1X1 ANT FEEDING. 

cases; they undoubtedly, however, belong to the osteo- 
genesis imperfecta or osteopathyrosis group. 

Heredity has been designated as a predisposing factor 
in exceptional cases. 

Prematurity is a predisposing factor to the develop- 
ment of the disease and the more prematurely born and 
consequently the more poorly the physiological func- 
tions are developed, the greater likelihood is there that 
the infant will suffer from rickets. Huenekens 1 found 
92 per cent, of his premature and twin pregnancies 
showed rickets in his series of sixty cases. He reports 
that 81 per cent, developed clinical evidence of rickets 
between the third and fourth month of life. Many of 
my prematures developed clinically evident rickets be- 
fore the end of their second month. This frequency 
and early development may be due to the fact that the 
mineral content of prematures is below normal, as two- 
thirds of the minerals are deposited during the last few 
months of fetal life, the fetus at six months containing 
thirty grams and at nine months one hundred grams. — 
Birk. 2 In the newborn, fully 75 per cent, of the ash 
content consists of calcium and phosphate, consequently 
rickets being a disturbance in the calcium and phosphate 
metabolism, the more premature the infant, the greater 
the deficiency in calcium and phosphorus, so that the 
surplus supply is exhausted earlier than in the full term. 

Underfeeding is another factor in the development 
of rickets in the premature. The low calcium content 
of human milk and the difficulty of metabolizing even 
this food in sufficient quantities to prevent drawing 
on the inherited supply may be an active factor. 
Huenekens 1 believes that this condition in the prema- 
ture may be a pseudo-rickets because it is based upon 
a deficiency in calcium rather than a disturbed calcium 
metabolism as in true rickets. 



1 Huenekens : Jour. Lancet, xxxvii, 804, Dec. IS, 1917. 

2 Birk and Orgler: Monatschr. f. Kinderh. 1, 1910, 544. 



RICKETS. 309 

Diet. The artificially fed are especially prone to de- 
velop severe rickets. If the diet contains sufficient milk, 
the tendency to develop the disease is less than when 
fed mainly on cereals and proprietary cereal foods with 
only small amounts of milk. 

McCollum, Shipley and their co-workers, 1 in a study 
of the effect on the growth and development in rats by 
the feeding of more than 300 different diets came to 
the conclusion that the etiological factor is to be found 
in an improper dietetic regimen. They were able to 
produce approximately normal nutrition and normal 
skeletal growth when properly constructed diets were 
fed. They were able to develop pathological conditions 
in rats corresponding in all fundamental respects to 
rickets in humans through dietetic insufficiencies : ( 1 ) By 
diminishing the phosphorus and supplying the calcium 
in optimal quantities or in excess, or (2) by reducing 
the calcium and maintaining the phosphorus at a con- 
centration somewhere near the optimal. They believe 
that rickets is essentially an expression on the part of 
the skeleton of disturbed relations between the calcium 
and phosphate ions of the body fluids and that there are 
two main kinds of rickets : one characterized by a nor- 
mal or nearly normal blood calcium and a low blood 
phosphorus (low phosphorus rickets) ; the other by a 
normal or nearly normal blood phosphorus but a low 
blood calcium (low calcium rickets). 

Due to the fact that when they fed diets containing 
a complete salt mixture, the rats did not develop rickets, 
even when there was an absence of fat-soluble vita- 
mine in the diet, they concluded that a deficiency in this 
substance cannot be the sole cause of rickets. They, 



1 McCollum, Simmonds, Parsons, Shipley: Jour. Biol. Chem., 
Vol. 45, 333, 1921. Shipley, Park, McCollum, Simmonds: John 
Hopkins Hosp. Bull., Vol. 32, 160. 1921. McCollum, Simmonds, 
Shipley, Park : Jour. Biol. Chem., Vol. 50, 5, 1921. Shipley, Park, 
McCollum, Simmonds: Am. Jour. Dis. of Children, Vol. 23, 91, 
1922. 



310 INFANT FEEDING. 

however, feel that these findings should not exclude the 
fat-soluhle substances from consideration as etiological 
factors in the production of rickets and kindred diseases, 
believing that there is a possibility that the blood phos- 
phate and calcium level may be determined in part by 
the amount of fat-soluble substances available for the 
needs of the organism. 

They pursued investigations with a view to determin- 
ing the nature of the substances contained in certain 
animal fats which protect the skeleton when the calcium 
content of the diet is unfavorable to the formation of 
normal bone. In this series of observations the phos- 
phorus content was in every case not far from the 
optimal. They were led to the conclusion that codliver 
oil contains in abundance some substance which is pres- 
ent in butter fat in but very slight amounts and which 
exerts a direct influence on the bone development. 
They further believe that this substance is apparently 
distinct from fat-soluble A. 

They made further studies on the effect of sunlight 
and ultra-violet rays on bone development. These ex- 
periments led them to suppose that in the absence of 
certain active light rays any influence which would re- 
sult in the depression of the calcium or phosphate ions 
in the body fluids with the formation of calcium-phos- 
phate ratios favorable for the development of rickets 
would ultimately produce the disease. 

Mellanby, 1 experimenting on puppies, was led to be- 
lieve that rickets was dependent upon calcium, phos- 
phorus, and fat-soluble vitamine deficiency, stating that 
foods which were rich in these substances prevented 
rickets, while those poor in them apparently caused it. 
He also believes that exercise is important in the pre- 
vention of rickets. 



1 Mellanby, E. : Experimental Rickets, Med. Research Council, 
London, 1921. 



RICKETS. 311 

Hess and Unger 1 carried out a series of experiments 
on the relation of fat-soluble A to rickets, but were un- 
able to confirm his findings. They studied institutional 
infants living under excellent hygienic conditions with 
good nursing and care, and food adequate in caloric con- 
tent and containing sufficient anti-scorbutic. Those fed 
large amounts of milk (24 to 32 ounces of raw or pas- 
teurized milk) developed rickets just as easily and to 
the same degree as the infants receiving only %o P er 
cent, milk fat. Those on low fat showed no greater 
signs of rickets than the average baby in the institution, 
even though at the most vulnerable age. The babies fed 
large amounts showed no symptoms of indigestion which 
might have resulted in an inability to properly metabo- 
lize their diet. They conclude that the fat-soluble vita- 
mine is not the much sought for anti-rachitic factor and 
that babies can thrive for a long period on a very limited 
amount of fat, providing that the diet is otherwise ade- 
quate. They feel that the infants must have utilized 
enough fat-soluble A vitamine from this large amount 
of milk fat, even if the vitamine content of the milk 
might have been small because of possible deficient diet 
of the cows. They state that it is their belief that 
rickets is primarily a dietetic disorder but that hygienic 
factors, such as sunlight, poor ventilation, and crowded 
quarters and infection, are important contributory 
agencies. 

It is a common clinical experience to find that diets 
containing a minimum of fats and salts, composed largely 
of carbohydrates, which usually means cereals, result in 
the development of rickets. This poorly balanced com- 
bination is strikingly seen in the feeding with proprie- 
tary infant foods, to which a minimum of milk is to be 
added. A sweetened condensed milk diet offers a good 
example of what may be expected from overheating, 
ageing, and a low fat and high sugar feeding. 



1 Hess and Unger : Jour. A. M. A., lxxiv, 217, Jan. 24, 1920. 



312 INFANT FEEDING. 

The theory of defective hygienic conditions and do- 
mestication, particularly in crowded cities, was first ex- 
pounded by von Hansemann. 1 Findlay 2 believes that 
poor housing conditions, lack of fresh air and exercise, 
are important factors. 

Hess and Unger 3 were the first to demonstrate by 
means of the roentgenograph that sunlight alone exerts 
a curative action in rickets. They also pointed out the 
possible role of actinic rays in an interpretation of the 
seasonal variation in the disease and expressed the 
opinion that it is the dominant factor in this incidence. 
They do not imply the diet is not of importance in the 
etiology of rickets, but rather that a hygienic factor — 
sunlight — also needs to be taken into account. They 
also confirmed the work of Huldschinsky and others, 4 
to the effect that the ultra-violet rays from a quartz lamp 
and other sources had a similar curative value. Powers 
and his co-workers 5 demonstrated the effect of the ac- 
tion of light in rickets in rats by a series of experiments. 
The diet used was the same in all animals and contained 
an optimal content of calcium and was decidedly below 
the optimum in its content of phosphorus and fat-soluble 
A, and in other respects it was well balanced. The 
experiments covered a period of two months. The ani- 
mals which were kept in sunlight with a daily average 
of four hours of exposure, did not develop rickets and 
became sexually active. The control animals, which were 
kept in an ordinary laboratory, showed all the gross and 
microscopic evidence of rickets. In the animals exposed 
to sunlight on this poorly balanced diet, while not show- 
ing rachitic changes in the bones, there resulted more 



i Von Hansemann: Berliner klin. Woch., 1906, 20—21. 

2 Findlay : Brit. Med. Jour. 13, July 4, 1908. 

Glasgow Med. Jour., 89, 268, May, 1918. 
Med. Res. Committee Report, 20, 1918. 

3 Hess and Unger: Jour. A. M. A., 77, 39, 1921. 

4 Huldschinsky : Deutsch. Med. Wochnschr., 45, 712, 1919. 

5 Powers, Park, Shipley, McCollum and Simmonds : Jour. A. 
M. A., 78, 159, 1922. 



RICKETS. 313 

delicate bone structure than in animals placed on a 
properly balanced diet under the same conditions ; show- 
ing that while the sunshine completely prevented the 
development of rickets it did not entirely compensate 
for the deficiency of phosphorus in the diet, as regards 
the growth and development of the rat as a whole, or 
of the skeleton, but did enable the organism to put into 
operation regulatory mechanisms which otherwise would 
have been inoperative or ineffective. 

The infection theory as a direct cause of rickets has 
few followers except insofar as infection may interfere 
with metabolism. 

The endocrine gland theory. The thyroid, parathy- 
roid, thymus, and adrenal abnormalities have each in 
turn been described as being closely related to the de- 
velopment of rickets, but in all probability the dysfunc- 
tion described has been secondary to the same factors 
causing the pathological changes in other tissues. 

From the accumulated data on animal experiments 
and clinical studies the conclusions must be drawn that 
the dietetic and hygienic theories offer the best solution 
of the pathogenesis of rickets. 

The question of race may predispose its development, 
as may heredity in exceptional cases. 

The seasonal incidence is probably influenced by the 
confinement and poor hygiene during the winter and 
spring months and the frequency of infections during 
this period of the year. In the artificially fed, the winter 
feed of the cows may be an element. 

Chronic constitutional and metabolic disturbances may 
act as contributory causes. 

Mineral metabolism. Schabad and others have shown 
that the calcium and phosphorus balance is disturbed in 
rickets, the excretion of both phosphorus and calcium 
being increased in the acute stage and decreased during 
convalescence. It is certain that the calcium and phos- 



314 INFANT FEEDING. 

phorus content of rachitic bone is much reduced from 
the normal. 

The following facts are known regarding the metabo- 
lism of calcium and phosphorus: There is practically 
always a sufficient amount of calcium in the infant's food 
to meet its requirements for health and growth, although 
a calcium dietary deficiency may be present in the ex- 
clusively breast-fed. Breast milk contains 2 Gm. of ash 
per 1000 mils and 0.458 Gm. of calcium per 1000 mils. 
Cow's milk contains 7.5 Gm. of ash per 1000 mils and 
1.72 Gm. of calcium per 1000 mils; thus the calcium 
content of cow's milk is four times that of human milk. 
The calcium in the milk is in organic combination al- 
though inorganic calcium may also be absorbed by the 
body. 1 

In Holt's 2 series of studies on calcium metabolism, 
healthy infants taking cow's milk modifications absorbed 
0.09 Gm. of calcium oxide per kilogram of body weight, 
while breast-fed infants absorbed 0.06 Gm. per kilogram. 
Somewhat older children, taking a mixed diet, absorbed 
0.055 Gm. per kilogram. All of these cases received a 
sufficient calcium intake. He further states that the in- 
take of calcium oxide should be at least 0.19 Gm. per 
kilogram to insure the average absorption of 0.09 Gm. 
per kilogram in the artificially fed and at least 0.13 per 
kilogram to insure an absorption of 0.06 Gm. per kilo- 
gram, the amount absorbed by the breast-fed. In gen- 
eral he found that 35 to 55 per cent, of the calcium in- 
take was absorbed. An excessive calcium intake did not 
increase the calcium absorption as the excess was ex- 
creted. If the intake of calcium oxide were very low, 
less than 0.10 Gm. per kilogram, the absorption of the 



1 Aschenheim and Kaumheimer : Monatsch. f . Kinderh. X. 
1911—12, 435. 

- Holt, L. E., Courtney, A. M., and Falcs, H. : Amer. Tour. Dis. 
of Children, Vol. 19, P. 97, Feb. 1920 and p. 201, March, 1920. 



RICKETS. 315 

CaO was below the necessary requirements, and a nega- 
tive calcium balance might develop. They found the best 
absorption of calcium obtained when the calcium intake 
bore a definite relation to fat intake. McCollum believes 
that in infants the reason that rickets develop is because 
the dilution of milk is such as to destroy or alter the 
proper mineral proportion when nothing else is added 
to the diet. 

Excretion of calcium is almost entirely through the 
intestines, especially the large bowel, only 5 to 10 per 
cent, being excreted by the kidneys. 1 Children suffer- 
ing from chronic intestinal indigestion show a low 
calcium absorption. 

A diminished calcium retention (negative calcium 
balance) exists in the florid stage of rickets, 2 even 
though the intake is ample. The calcium retention re- 
turns to normal when the disease is cured, but during 
recovery the absorption is higher and the excretion in 
the stools less than normal. 3 Howland and Park 4 have 
demonstrated a beginning calcium deposit in the bones 
of animals two days after beginning the administration 
of codliver oil. By the end of the third week after be- 
ginning the administration of codliver oil, calcium de- 
posits can be demonstrated in the cartilages of human 
beings by means of the roentgenogram. 

In prematures there is very low calcium retention dur- 
ing the first month of life, according to Hamilton. 5 This 
is probably dependent on several factors, among the 
most important being the low mineral content of pre- 
maturely born infants, and the restricted intake of foods 
with low calcium and phosphorus content, as is found 



i Voit, E. : Zeitschr. f. Biol., 1880, xvi, 55. 
2 Schabad : Arch, f . Kinderh., 1910, liii, 380. 
3 Holt, L. E., Courtney, A. M. and Fales, H. : Am. lour. Dis. 
of Children, Vol. 19, p. 97, Feb., 1920, p. 201, March, 1920. 

4 Report of the 32d Meeting of Amer. Pcd. Soc. Arch of Ped. 
xxxvii, 411, July, 1920. 

5 Hamilton: Am. Jour. Dis. of Children, Vol. 20, 316, 1920. 



316 INFANT FEEDING. 

in breast milk and cow's milk in high dilutions. These 
infants almost invariably suffer from severe secondary 
anemias, dependent upon the same causes. Both rickets 
and secondary anemia are frequently prominent in this 
class of infants by the end of the second month of life. 
Rachitic premature infants also show bone changes which 
present a different pathological picture from the later 
rickets seen in full term infants, in that the skull is 
involved out of proportion to the clinical findings in the 
extremities and thorax. The result is a megacephalus 
characterized by a large, round head with prominent 
frontal and parietal eminences and open sutures, while 
the changes in the ends of the long bones and costochon- 
dral junctions show only a moderate degree of involve- 
ment. 

The average normal blood calcium content for infants 
under 1 year of age is 10 to 11 mg. per 100 mils of serum. 1 
Kramer and Howland 2 have demonstrated that the cal- 
cium concentration in the serum in normal children is 
singularly constant, so that even small deviations are 
regarded as diagnostic of disorder. 

As previously stated, dependent upon the blood pic- 
ture, there are in all probability two main kinds of 
rickets. One is characterized by a normal or nearly 
normal blood calcium and a low blood phosphorus ; the 
other by a normal or nearly normal blood phosphorus 
but a low blood calcium. The investigations of How- 
land and Kramer, 3 and of Kramer, Tisdall and Rowland, 4 
on the calcium and phosphorus content of the blood 
serum in rickets and tetany have given suggestive evi- 
dence in support of this idea. These observers found 
that in children suffering from rickets alone, the phos- 



i Brown, A. : Am. Jour. Dis. of Children, Vol. 19, 413, 1920. 

2 Kramer, B., and Howland, J. : Jour. Biol. Chem., xliii, 35, 1920. 

3 Howland, J., and Kramer, B. : Am. J. Dis. of Children, 22, 
105, 1921. 

4 Kramer, B., Tisdall, F., and Howland, J. : Am. J. Dis. of 
Children, 22, 431, 1921. 



RICKETS. 317 

phorus of the blood serum is low, and the calcium not 
far removed from the normal ; in children suffering 
from manifest tetany complicating rickets, on the other 
hand, the calcium is low but the phosphorus often not 
far removed from normal. 

Phosphorus Metabolism. Phosphorus is contained in 
milk in the following forms : inorganic . calcium phos- 
phate, and as organic in combination with casein, nuclein, 
lecithin, etc. There is 0.294 to 0.418 Gra. per 1000 mils 
in human milk, of which 43.3 per cent, is organic, and 
there is an average of 2.437 Gm. per 1000 mils in cow's 
milk, of which 46 per cent, is organic. 

Schabad 1 states that two-thirds more of the phos- 
phorus is normally excreted by the kidneys, the rest 
from the bowel, the proportion being 80 :20 in the breast- 
fed and 60 :40 in the artificially fed- During florid rick- 
ets the relations are 65 :35 and 40 :60 respectively, and 
there is an absolute increased excretion of phosphorus. 
As the disease is arrested the proper proportions are re- 
established and for a time there is a greater retention 
of phosphorus than normal. Howland and Kramer 2 
have shown that the blood phosphate is low in the blood 
plasma of rachitic children, and that the administration 
of codliver oil causes a marked rise. Hess and Gutman 3 
have demonstrated similar changes following exposure 
to the sun's rays and by use of quartz lamps. 

The phosphorus of the blood can be increased by 
feeding phosphorus per mouth. Marriott, 4 worked with 
artificial blood, found that by small increases in the phos- 
phorus content, a precipitate resembling in composition 
the salts of bone was formed. Wegner 5 found that feed- 



i Schabad : Arch. f. Kinderh., 1910, liv, 83. 

2 Howland and Kramer: John Hopkins Hospital Bulletin, May, 
1921, p. 165. 

3 Hess, A. F., and Gutman, P. : Proc. Society Exper. Biol, and 
Med., 19, 31, 1921. 

4 Report of 32d. Meeting of Am. Ped. Soc, Arch, of Ped., 
xxxvii, July, 1920. 

•"' \\ egner : Virchow's Arch. f. Path. Anat., 1872, 55, 9. 



318 INFANT FEEDING. 

ing small doses of phosphorus to young, growing dogs 
and cats, caused an increased new bone formation, espe- 
cially in the diaphysis along the epiphyseal lines. Adult 
bones were not affected. Kassowitz 1 confirmed the above 
work but noticed that feeding too large a dose of phos- 
phorus caused osteoporosis. Phemister 2 applied these 
experiments to children and noticed by roentgen ray 
studies that phosphorus affected the normal bones of 
children as it did Wegner's animals and that the ac- 
cumulation of calcium and overproduction of bone in the 
metaphysis continued for some time, even after the ad- 
ministration of phosphorus was discontinued. He 3 has 
more recently reported similar results in rachitic infants. 
Further Relation of Diet to Calcium Metabolism. 
Howland 4 has demonstrated that carbohydrates in the 
diet favor a calcium retention. Freund 5 has shown that 
an excess of fat in the diet may cause a negative calcium 
balance. Holt found that the best absorption of cal- 
cium occurred when the food contained from 0.045 to 
0.060 Gm. of calcium oxide for every gram of fat and 
the fat intake was ample, not less than 4.0 Gm. per kilo- 
gram. On a mixed diet a slightly lower proportion of 
calcium oxide to fat was needed to insure good absorp- 
tion of calcium oxide. No constant relation between 
calcium and fat excretion was found. Lindberg. how- 
ever, demonstrated that in the breast-fed a high fat in- 
take (breast milk enriched with added breast milk fat) 
may lead to at least temporary losses of calcium. This 
increased fat intake was followed by an increased fat 



1 Kassowitz : Ztschr. f. Klin. Med., 1884. 

2 Phemister, Effects of phosphorus on growing normal and dis- 
eased bones ; Jour. Am. Med. Assn., 70—1737, June 8, 1918. 

3 Phemister, Effects of phosphorus on growing normal and dis- 
eased bones; Jour. Am. Med. Assn., 70 — 1737, June 8, 1918. 

4 Howland and Marriott : Am. J. Obstet., 1916, lxxiv, 541. 

5 Freund: Jahrb. f. Kinderh., 1905, lxi, 36. 
c Linberg: Ztschr. f. Kinderh., xvi, 90, 1917. 



RICKETS. 319 

excretion. Hamilton 1 suggests that the poor calcium 
retention in prematures may be related to the relatively 
large excretion of fat as their characteristic feces are 
rich in fats. Protein apparently has no influence on the 
calcium retention. 2 

Summarizing, it may be stated that rickets is a nutri- 
tional disturbance especially affecting the osseous, mus- 
cular, and nervous systems, with resulting lesions due 
to improper utilization of calcium and phosphorus. 

Pathological Anatomy. In rickets the most charac- 
teristic changes are in the skeleton. The changes are 
distributed over the entire osseous system and become 
essentially manifest in those areas of the most active 
bone growth. 

The following must be emphasized as characteristic 
factors of the rachitic bony process : hyperemia of the 
bones; irregular formation and proliferation of the tis- 
sues in which normally osseous formation occurs; de- 
ficient deposit of calcium in these tissues, and the patho- 
logic decalcification of bones that already contain calcium. 

The normal production of bone occurs in the peri- 
osteum and at the osteochondral borders, and here the 
essential anatomical factors of rickets are established. 

The periosteum is for the most part decidedly thick- 
ened. The thickening is due to a hyperemic layer be- 
tween the fibrous periosteal cover and the bone, consisting 
of alternate porous, plexus-like tissue and coarse longi- 
tudinal bands. Microscopic investigation reveals a sub- 
stratum, rich in cells, which is interrupted by medullary 
vascular spaces. 

Section of a normally growing bone reveals between 
the osseous and cartilaginous structures a limited and 
sharply-defined bluish zone of calcification several milli- 
meters in thickness. I [istologically the bone formation 
appears about as follows: Cutting centerward from the 



1 Hamilton, B.: Am. Jour. Dis. of Children, 20—316, Oct., 1920. 
2 Tada: Monatschr. f. Kindcrh., 1905— 06, iv, 118. 



320 INFANT FEEDING. 

cartilaginous epiphysis we find that the cartilage cells, 
which were at first deposited irregularly, arrange them- 
selves in definite rows corresponding to the direction of 
growth, and begin to enlarge. The intermediary sub- 
stance of these cell columns takes up lime salts and then 
becomes the zone of provisional calcification. From 
points of vascular ossification in these layers of cartil- 
aginous proliferation capillaries originate which cause 
resorption of the cartilaginous tissue and form medullary 
spaces, in the walls of which, by proliferation of cells 
introduced through the vessels (osteoblasts), true bony 
tissue forms and soon becomes a compact structure by 
deposition of calcium salts. 

In well-developed rachitic bones these conditions are 
essentially changed. The osteochondral boundary is 
markedly widened- — to 1 cm. in thickness — and conspicu- 
ously red. In contrast to the normal cartilage the end 
is not sharp but serrated. As in the normal bone, the 
cartilaginous cells are first arranged in rows and after- 
wards clump together, forming larger nests. The en- 
largement of the cartilage cells, however, is much greater. 
The lines of direction are less conspicuous the closer we 
approach to the diaphysis. The proliferating capillary 
branches permeate this "chondroid" tissue much more 
deeply than in the normal bone, so that in place of a 
uniform approximation of the cartilage columns and 
medullary spaces there is a quite irregular interlacing 
of these histologic elements. Of essential importance in 
rickets is the fact that through the action of osteoblasts 
a structure arises which resembles bony tissue ; this os- 
teoid tissue, however, as was seen in the periosteum, dif- 
fers micro-chemically from true decalcified bony tissue 
and shows but slight tendency to calcification. 

Therefore, in the enchondral ossification, there is an 
enlargement of the zone of transformation, a marked 
hyperemia of the same, as well as the formation of oste- 
oid tissue and delayed calcification. The last factor is 



RICKETS. 321 

of essential importance in rickets. There is a conspicu- 
ous disproportion between the broad transitional zone, 
which is ready for ossification, and the slight deposit of 
calcium which is found there. The consequences of this 
is an abnormal softness at the epiphysis and a ready 
separation of the epiphysis from the diaphysis. 

The bones are markedly hyperemic, alike in the peri- 
osteum, in the zones of ossification, and in the marrow. 
Through the great proliferation and the deficient calci- 
fication of the periosteum, as well as from the absorp- 
tion of bone, they are abnormally soft. This gives rise 
to the many deformities and curvatures of the skeleton 
with which we have become familiar from the symp- 
tomatology. In addition there may be infractions and 
fractures which affect the shape of the bones of the 
extremities and the clavicle. A further consequence 
which has been mentioned is the softness and protuber- 
ance of the osteochondral borders of the long bones. 
Finally, there is an irregular periosteal deposit and by 
softening processes in the flat bones of the skull an ir- 
regular thickening and thinning is produced, the borders 
of the bone being thickened, the thinness affecting prin- 
cipally the squama of the occipital bone and the depen- 
dent portions of the parietal bones, in which probably 
unfavorable conditions are brought about by opposing 
pressure of the brain and the overlying surface. 

In this series of bony changes all of those anomalies 
of the skeleton may be included which are met with in 
rickets: Craniotabes, the rosary, narrowed pelvis, and 
finally, the curvatures and deformities of the thorax and 
extremities. 

The changes which the skeleton shows after healing 
of the process are better understood. After the zone of 
proliferation in the osteoid tissue is finally impregnated 
with lime salts and has undergone ossification, the bone 
becomes thicker, harder, distorted, and its surface beset 
with rough edges and osteophytes. This condition is 

21 



322 INFANT FEEDING. 

especially distinct in the tubular bones, which lose their 
graceful contour, become heavier, and sometimes retain 
the shape which was produced in the florid stage by 
curvatures and infractions. These thickenings also oc- 
cur in the cranial bones. The influence upon the per- 
manent teeth, the pelvis and the longitudinal growth of 
the tubular bones has already been mentioned. 

A very interesting question, although at this time ob- 
scure, is whether the organs of the body, as well as the 
skeleton, are affected in a characteristic manner by the 
rachitic process. This pertains especially to the brain, 




Fig. 12.— D. V. First stage of rickets. Taken March 
1921, before beginning of phosphorized codliver oil therapy. 
The metaphysis is pale and hazy. The epiphysis of the upper 
end of the shaft of the tibia is not visible and at the lower 
end of the shaft is seen as an indefinite shadow. The 
periosteum appears as if separated from the shaft by a layer 
of osteoid tissue. 

the spleen, the blood, the liver, and perhaps the muscles; 
the frequent pathologico-anatomical findings in the lungs 
and in the heart are of a secondary nature, and in the 
digestive tract no regular form of affection is noted. It 
is true the anatomical findings in the organs mentioned 
are not well-defined, and are by no means characteristic 
of rickets, but the relatively common occurrence of 
megacephalus and enlargement of the spleen and of the 



RICKETS. 323 

liver, as well as the rarer hypertrophy of the brain, in 
connection with the rachitic fundamental process cannot 
at once be ignored. 

Schmorl, 1 in his studies of healing rickets, found that 
the initial deposition of calcium occurring at the cartil- 
age-shaft junction of the long bones takes place not 
throughout • the rachitic metaphysis or at random in it 
but on the epiphyseal side of the metaphysis in that zone 
of the proliferative cartilage in which calcium deposition 
normally occurs and presumably would have occurred 
had rickets never been present. Figs. 12, 13, 14. 




Fig. 13.— D. V. Taken April 26, 1921 after 28 days treatment 
with phosphorized codliver oil and a well balanced diet. 
A line of deposition of calcium salts is seen in the proliferat- 
ing zone of the cartilage, at right angles to the long axis of 
the shaft. This deposit is most marked on the epiphyseal side 
of the metaphysis. The epiphyseal nucleus at the upper end 
is plainly visible and the one at the lower end shows an in- 
creased shadow density. . 

Recent investigations by Shipley, Park, McCollum, 
Simmonds and Parsons, 2 on the results following the 
feeding of codliver oil to rachitic rats, confirmed these 



1 Schmorl, G. : Ergcbn. d. inn. Med. u. Kinderh., 13 — 403, 1914. 

2 Shipley, Park, McCollum, Simmonds, Parsons — Jour. Biol. 
Chem., xlv, 343, 1921. 



324 INFANT FEEDING. 

findings. They found that when the cartilage had be- 
come free from calcium as the result of the deficient 
diets, the addition of codliver oil to the food for a period 
of from two to seven days was followed by deposition of 
lime salts between the cells of the proliferative zone of 
cartilage. The deposit of calcium salts is linear, the 
width of the line apparently depending on the length of 
time during which the animal has been fed codliver oil. 
The line of deposition is at right angles to the long axis 




Fig. 14.— D. V. Taken May 11, 1921, 43 days after Fig. 14. 
Shows an increased length of the shaft due to calcium de- 
posits at the epiphyseal side of the metaphysis. The increased 
length of the shaft at the lower end is about 2 mm. The 
nuclei at the upper and lower ends of the shaft are now dis- 
tinctly visible and clean cut. Calcium has been deposited in 
the subperiosteal osteoid tissue and there is no longer the ap- 
pearance of periosteal separation. 

of the shaft of the bone. From the appearance of their 
sections it seems that very little lime salt is laid down 
in the osteoid tissue until calcification of the prolifera- 
tive cartilage is complete. 

The gross pathology in premature infants differs some- 
what from that in mature infants. Megacephalus is 



RICKETS. 325 

commonly observed. Along with this condition there 
is a symmetry of the skull which is produced mechani- 
cally by pressure on the infant's especially soft skull in 
the first months of life. The rachitic rosary is very 
prominent in prematures and is explained on the basis 
of the constant respiratory movements leading to de- 
formities and marked enlargement of the epiphyses of 
the ribs. The chest is narrow and early shows the 
rachitic grooves. The long bones, however, only show 
moderate enlargements of the epiphyses in prematures, 
although rachitic changes appear very early in these 
bones. The bone absorption and fringing of the epiphy- 
seal line with marked haziness at the end of the shaft, 
predominate rather than the increased proliferation 
which is the rule in full term rachitic infants. Probably 
the explanation for this is that the rickets appearing 
very early is terminated before the infant crawls or 
walks and so the compensatory proliferations from pres- 
sure and weight-bearing are not present. Consequently 
rickets may occur in prematures without the epiphyseal 
enlargement and curvatures of the long bones. The 
histological examination shows the characteristic picture, 
however, even in the absence of marked external mani- 
festations. 

Symptoms. The outstanding symptoms of well 
developed rickets will not be described here. It is, how- 
ever, very important to be thoroughly familiar with the 
early symptoms of rickets, as in the first stage, before 
permanent damage has been done, it responds most 
readily to treatment. The first evidences of rickets may 
escape attention unless the examiner considers the pos- 
sibility of its presence from the history. Fretfulness, 
irritability, restless sleep and excessive perspiration about 
the head are among the earliest signs. These children 
are usually pallid and show considerable evidence of a 
secondary anemia. Constipation frequently appears early 
and may alternate with diarrhea. There is soon noted 



326 



IX FA XT FEEDIXG. 



a more or less evident backwardness in physical develop- 
ment ; the child may be unable to hold up its head and, 
at later age, to sit up or stand as a normal child would 
at the same age. (Fig. 15.) The muscles are flabby, 
the abdomen distended and tympanic, and an umbilical 
hernia is a frequent complication. (Fig. 16.) As the 
condition advances the anemia becomes more marked 




Fig. 15. — H. G. Colored infant, showing an extreme degree 
of rickets. The head, extremities, chest and abdomen show 
the typical deformities. A large umbilical hernia is present. 



and there is a tendency towards splenic enlargement. 
Among the earliest changes in the skeleton is the develop- 
ment of beading of the ribs at the costochondral junc- 
tions forming the socalled rachitic rosary. In the 
severer types this is followed by a sinking in of the ribs 
in the axillary line and a flaring out of the ribs below, 
the latter being due to the support furnished by the 



RICKETS. 



327 




Fig. 16. — H. G. Same infant, showing the descending colon, 
sigmoid and rectum distended by a barium enema. The 
megalocolon and enormous sigmoid account to a large ex- 
tent for the abdominal enlargement and constipation in this 
case. 



328 INFANT FEEDING. 

intra-abdominal organs. The depression at the costo- 
chondral junctions, described as Harrison's Groove, is 
to a large extent due to the traction on the chest wall 
by the diaphragm. The skull usually shows enlarged 
veins, and is squared in front, flattened on top, and has 
marked frontal and parietal eminences. The fontanels 
are late in closing, as are the sutures. Craniotabes is 
one of the pathognomonic findings. At the junction of 
the epiphyses and diaphyses nodular enlargements be- 
come palpable in the long bones and are most easily 




Fig. 17. — H. G. Same infant, showing the extreme changes 
of a florid rickets. The typical enlargement of the soft parts is 
noticeable in the outline of the wrists. The lower ends of 
the shafts of the radius and ulna show the typical cupping 
and sawtoothed appearance. The epiphyseal nuclei are widely 
separated from the shafts and the nucleus of the radius is 
displaced and fragmented. Similar changes are seen in all 
of the metacarpal bones and the phalanges. 

recognized at the wrists, knees, and ankles. (Fig. 17.) 
Dentition is frequently delayed and irregular. The 
primary teeth are subject to early decay. Deformities 
are common and may develop in any part of the osseous 
system, most commonly involving the long bones, verte- 
bral column, and pelvis, as well as the head, previously 
described. The blood changes are not characteristic, 
usually being those of a secondary anemia, with a marked 



RICKETS. 329 

reduction in the hemoglobin and red blood corpuscles, 
and not infrequently a moderate leucocytosis is present. 
The nervous phenomena, secondary to rickets, are among 
the most important from a therapeutic standpoint be- 
cause of their reaction to proper treatment. They in- 
clude all of the findings described under spasmophilia. 

Of the greatest importance are the radiographic studies 
of the first and second early stages. These have already 
been described in the discussion of the gross bony path- 
ology. These changes allow of a diagnosis often four 
to six weeks before the disease results in sufficient bone 
changes to be evident on physical examination. 

Radiographic Diagnosis. Radiographic studies closely 
follow the macroscopic appearance of the bones. In the 
first stage the epiphyses cast little or no shadow, while 
the center of ossification is small or absent and at times 
appears multiple. These epiphyseal findings are easily 
explained by the interspersing of cartilage masses be- 
tween the newly deposited osseous tissues, and are visi- 
ble upon microscopic examination of fresh bone sections 
and often on macroscopic examination. The diaphysis 
becomes frayed out, instead of clear-cut, the periosteum 
thickened, and the joints appear hazy. 

In this stage a wide separation of the epiphysis from 
the diaphysis is frequently noted, due to the lack of bone 
deposit in the proliferating zone or metaphysis. Multi- 
ple fractures are common. 

In the second stage the shadow of the epiphysis be- 
comes more marked, and the epiphyseal line is more 
ragged and irregular. The metaphysis is widened with 
an irregular saw-toothed appearance on the epiphyseal 
side and there is also a broadening and flaring of the 
epiphyseal line which is very characteristic. This con- 
tinues into the third stage, and the space between the 
proliferating zone and the epiphyseal nucleus is lessened 
by a distance corresponding to the new bone deposit and 
epiphyseal growth. This growth can be measured on the 



330 INFANT FEEDING. 

plates. Further changes in the second stage consist in 
the chambering of the interior of the bone, where light 
areas in the shaft indicate the absence of bone deposit, 
and heavier lines of ossification show the irregular de- 
velopment of trabecular There is usually a thickening 
on the concave side of the shaft, which is a compensatory 
change. The second stage is generally a period of sys- 
temic reaction to the disease, in which signs of returning 
ossification occur and when deformity begins. In the 
third stage, the epiphysis begins to resume its normal 
contour and homogeneous shadow density. Irregulari- 
ties persist in the marginal outline, and there is still a 
little mottling in the ossification. The lipping of the 
diaphyses has enlarged the bone ends, and there is in 
consequence a discrepancy in breadth between the di- 
ameters of the diaphysis near the epiphyseal line and the 
epiphysis. 

These bony changes and the softening of the bone 
gives rise to all the various bony deformities of clinical 
rickets. 

Prognosis. The disease is chronic, and lasts for 
months or up to the end of the first dentition. Its 
course is modified by treatment. Periods of latency and 
exacerbation depend on diet and hygiene and are influ- 
enced by season and secondary infections. Usually, 
active symptoms subside when a mixed diet is given — 
that is, at about the end of the first year. 

Different parts of the skeletal system are progres- 
sively involved, recovery taking place in one while an- 
other is becoming affected. In the first six months of 
life craniotabes, beading and enlarged epiphyses may be 
the only physical signs. Later on the thorax becomes 
deformed, and then kyphosis and curvatures of the bones 
develop. The signs of improvement are diminished 
sweating and restlessness, disappearance of craniotabes 
and anemia, increasing muscular power, and improved 
general nutrition. Deformities slowly and steadily im- 



RICKETS. 331 

prove except in very bad cases, in which they persist to 
a variable degree throughout life, in the shape of pigeon- 
breast, Harrison's groove, eversions of the costal arch, 
kyphosis, pelvic deformity, knock-knee, bow-legs, and 
flat-foot. 

Rickets is never fatal per se, but it reduces the resist- 
ing power, and is an important cause of increased mor- 
tality from other diseases, especially catarrhal affections 
of the alimentary and respiratory systems. Death may 
also result from spasmophilic manifestations, more es- 
pecially convulsions. The thoracic deformity retards 
growth by interfering with efficient lung expansion and 
oxidation. Impaired epiphyseal growth may affect 
growth in height, and the malnutrition may delay mental 
development. Rachitic children often talk late and learn 
new words slowly. 

Treatment. In a consideration of the treatment of 
rickets prime importance must be placed upon a careful 
study of the previous diet and life history of the infant. 
First, in a consideration of the preceding diets, the cases 
may be classified into those which have been wholly or 
largely breast-fed. In this group the general health of 
the mother and her diet must be investigated. The 
quantity of her milk should be estimated. Unfortunately 
the quality can usually only be judged by the effect on 
her offspring. The second group of cases are those de- 
pendent upon cow's milk as the main article in their 
diet. In this group the source and quality of the milk 
as well as the quantity must be considered. The diet 
usually errs in the direction of insufficiency, however, 
an excess of cow's milk may result in a disturbed meta- 
bolic balance with a secondary disturbance in calcium 
retention. The third group of cases are those dependent 
upon proprietary infant foods which contain coiv's milk. 
The danger in feeding those containing cow's milk usu- 
ally lies in the fact that the quantity of cow's milk they 
contain is insufficient, or its chemical composition is 



332 INFANT FEEDING. 

changed in its preparation, and its vitamine content des- 
troyed by heating and ageing. The caloric value in this 
class of foods is largely dependent upon the carbohydrates 
contained and added while their fat and protein is usually 
low. The fourth group are those fed on proprietary 
foods containing little or no cow's milk and which are 
composed largely of dextrinized cereals which have been 
devitalized through long continued heating and are dan- 
gerous because of a second factor, namely, the instruc- 
tion to feed them with an insufficient quantity of cow's 
milk and other needed food elements. 

Breast feeding must be encouraged. The lactating 
mother's diet should be rich in milk, eggs, butter 
and green vegetables. These may be supplemented by 
cereals, root vegetables and muscle-meat, but it is to be 
emphasized that the latter group are decidedly inferior 
to the former in the furnishing of needed minerals (es- 
pecially calcium and phosphorus) and vitamines in the 
breast milk. 

If the breast milk becomes deficient, either qualita- 
tively or quantitatively, mixed feeding must be instituted. 

In artificially fed infants the disease is usually present 
during the second quarter of the first year, although it 
may not be clinically manifest until a much later period. 
A proper diet at any age should contain sufficient fat, 
protein, carbohydrate, salts and vitamines. In most in- 
stances, cow's milk must in greater part furnish these 
necessary elements. The cow's milk should be supple- 
mented as soon as possible by the addition of fruit juices 
and codliver oil. Fresh cereals, in the form of well- 
cooked gruels, can usually be added by the fourth month 
of life and fresh vegetables in the form of a vegetable- 
cereal-meat soup, can be started in the sixth month. 
Vegetable purees may be added by the eighth or ninth 
month. The vegetables, whether contained in soup or 
when given as purees, should be passed through a fine 
sieve. The addition of fruit juices, cereals and vege- 



RICKETS. 333 

tables should be considered in the light of prophylactic 
treatment against rickets. The careful study of the 
whole diet should be undertaken and a generous diet, as 
above outlined, should be instituted as routine in the 
feeding of all infants. 

Not infrequently the diets of cases developing rickets 
are also low in the anti-scorbutic element, making the 
early addition of fruit juices and cooked fruits of addi- 
tional value. In the formulating of the diet in these 
cases, the presence of the secondary anemia which so 
commonly accompanies rickets must be considered and 
the iron containing foods should be added in sufficient 
quantities. For this purpose the green-leafed vegetables 
and meat juices or scraped meat pulp are of great value. 
Therefore, in rickets a varied diet may be instituted in 
every case as soon as it can be utilized. However, the 
new food elements must be added one at a time and 
subsequent changes made only after it has been ascer- 
tained that the infant can digest the previous diet. Sud- 
den and radical changes in the diet may lead to serious 
gastro-intestinal and systemic complications. 

Hygienic Treatment. The infant should receive 
plenty of fresh air and sunshine. The practical value 
of the direct action of the sun's rays in the treatment 
of rickets has been conclusively demonstrated. The 
weather permitting, they should be outdoors for several 
hours a day, varying the period according to the weather. 

"Mothering" in the form of exercise, handling and 
light massage, are invaluable to all infants. This is 
especially true of infants in institutions. 

The susceptibility of rachitic infants to respiratory 
infections must be remembered and every means em- 
ployed to prevent systemic depression due to exposure to 
rapid changes of temperature. Because of the increased 
susceptibility of rachitic children to infections, they 
should be protected as far as possible from any contact 



334 INFANT FEEDING. 

with infectious cases. Slight colds may result in serious 
systemic infections. 

Sunlight. Experimental evidence showing the favor- 
able action of sunlight on the mineral metabolism was 
furnished by Raczynski 1 in 1912. He showed that in 
rickets a deposition of salt in the bones may be accom- 
plished without any addition or alteration in the diet. 
He took two puppies of the same litter, both of which 
were being suckled by the mother, and kept one in abso- 
lute darkness and the other, throughout the day, in sun- 
light. At the end of a six weeks' period both were 
killed. An analysis of their bodies showed that the one 
which had been reared in the sunlight contained over 50 
per cent, more calcium and 25 per cent, more phos- 
phorus than the other, but that on the contrary, it con- 
tained less than half the quantity of chlorin. 

Powers and his co-workers 2 in a series of experiments 
on rats, using a diet which in ordinary room-light gave 
rise to a disease in its essential features identical with 
rickets as seen in human beings, used a diet high in 
calcium, low in phosphorus and insufficiently supplied 
with fat-soluble A. In other respects it was well con- 
stituted. All control rats kept in room-light developed 
rickets, while rats exposed regularly to sunlight on an 
average of four hours a day remained, without excep- 
tion, entirely free from rickets. The animals, however, 
remained under-sized ; the bones, though completely cal- 
cified, remained thin. These experiments lead them to 
believe that even in the presence of a defective diet, the 
sunlight raises the efficiency of the body cells. The fa- 
vorable effect of sunlight in rickets has recently been 
emphasized by Feer. 3 He calls attention to the marked 
benefit which accrues in rickets from exposure to the 



1 Raczynski, J. : Compt-Rend. de L'Ass'n., Internat. de Pediat., 
Paris, 1913, 108. 

- Powers, Park, Shipley, McCollum and Simmonds : J. A. M. 
A., 78, 3, January, 1922. 

3 Feer, E. : Schweiz. med. Wchnschr., 51, 438, 1921. 



RICKETS. 335 

sun's rays in the Swiss Alps. Riedel 1 reports a series 
of cases treated with sunlight on bright days and supple- 
menting the treatment with a quartz lamp on sunless 
days, with excellent results. 

Huldschinsky made use of sunlight together with the 
ultra-violet rays in some of his series, and Riedel relied 
on treatment with sunlight. Hess and Unger 2 demon- 
strated, by means of the roentgen ray, that sunlight pos- 
sesses a curative action in rickets of human beings. They 
exposed five infants with rickets to the direct action of 
sunlight for periods varying from one-half hour to sev- 
eral hours daily, whenever the sunlight was available. 
Different parts of the body were in turn subjected to 
the action of the sun's rays. In one of the cases the 
patient was exposed to the sunlight only on seven occa- 
sions, for a total period of twenty-five hours. The gen- 
eral condition of the infant's health, as well as the dis- 
eased condition in the bones, was benefitted. 

Ultra-violet Rays. Since Bucholz, 3 in 1904, reported 
his good results in the treatment of rickets by artificial 
light and heat, by exposure to the rays of a special lamp, 
little attention has been paid to this form of therapy 
until the publication of the work of Huldschinsky, 4 in 
1919. The latter made use of the quartz lamp. In 
December, 1918, Winkler 5 reported the favorable effects 
of treatment of rickets with the roentgen ray. He used 
a medium soft tube at a focal distance of about 20 cm. 
The exposure did not exceed ninety seconds and was 
repeated every other day. The treatment at first was 
directed against the craniotabetic lesions of the head. 



1 Riedel, G. : Munchen med. Wchnschr., 67, 838, July, 1920. 

- 1 less, A. !•". and Unger, L. J. : Amer. Jour. Dis. of Children 
Aug. 1921, 186. 

3 Bucholz, E. : Vcrhandlung dor Gessellschaft fur ECinderheil- 
kunde in der Abteilung fur Kinderheilkunde der 76 Versammlung 
der Gessellschaft Dcutscher Naturforschcr und Aerztc in Breslau 
21, 116, 1904. 

1 Huldschinsky, K. : Deutsch. med. Wchnschr., 45, 712, 1919. 

"Winkler, F. : Monatschr. f. Kindcrh., 15, 520, Dec. 1918. 



336 INFANT FEEDING. 

After five or six treatments, he observed that the sweat- 
ing of the head came to an end and sleep was improved. 
As the treatment progressed, laryngospasm and the ten- 
dency to convulsions disappeared. The craniotabes van- 
ished, the teeth erupted and the calcium deposition oc- 
curred at the end of the long bones. In 1920 Putzig 1 
used the quartz lamp in the treatment of rickets in pre- 
mature infants, with good results. In 1920 Riedel 2 and 
in 1921 Erlacher 3 reported further cures with the use 
of the ultra-violet rays, and in 1921 Mengert 4 announced 
the successful use of the quartz lamp as a prophylactic 
agent against rickets. He claims it to be especially good 
in the prophylactic treatment of prematures. In 1921, 
Hess and Unger 5 also reported the cure of rickets by 
means of the ultra-violet rays. They report a group 
of infants, varying in age from 8 to 21 months, which 
were treated during the months of February and March, 
the period of the year when rickets is likely to manifest 
its highest incidence and least apt to decrease in severity. 
During the period of treatment no changes were made in 
the diet. Marked improvement in the bones was demon- 
strated by means of roentgenograms, and the hemoglobin 
percentage and number of red cells increased in every 
instance. The infants were treated three times a week 
for a period of two months. The entire body was ex- 
posed to the rays, at first for a period of about three 
minutes, the length of exposure being increased gradu- 
ally to twenty minutes. 

Kramer, Casparis and Howland 6 found that by syste- 
matic exposure to the rays from the mercury vapor quartz 
lamp the inorganic phosphorus concentration of the 



i Putzig, H. : Therap. Halbmonatschr., 8, 234, April, 1920. 

2 Riedel, G. : Munchen med. Wchnschr., 67, 838, July, 1920. 

3 Erlacher, P. : Wien. klin. Wchnschr., 34, 241, May, 1921. 

4 Mengert, E. : Deutsch. med. Wchnschr., 47, 657, June, 1921. 
•"' Hess, A. F. and Unger, L. J. : Ibid, 13. 

Kramer, B., Casparis, H., Howland, J. : Amer. J. Dis. of 
Children, xxiv, 20, 1922. 



RICKETS. .337 

serum of these children which was low (from 2.7 to 3.2 
mg.) before the treatment was begun gradually increased 
to a maximum of 6 mg. with the appearance of calcium de- 
position in the bones. So far as could be judged, heal- 
ing of the bones following radiation occurred at about 
the same time as it does after the administration of cod- 
liver oil. The changes in the phosphorus concentration 
of the serum were identical with those observed after 
codliver-oil treatment. 

It is my practice to begin with 50 cm. distance for 
three minutes, gradually increasing the time of exposure 
to twenty minutes by the end of the second month. At 
least three treatments should be given each week — when 
possible they should be given daily. The entire body 
should be exposed, the ventral and dorsal aspects being 
radiated during alternate treatments. The eyes must be 
protected by suitable glasses. 

In using the quartz lamp in practice I apply the follow- 
ing exposures as suggested by Gerstenberger : 

1st Month: 

Total Exposures 12. 

At 80 cm. for 5, 7, 9, 11 minutes. 

At 75 cm. for 7, 9, 11, 13 minutes. 

At 70 cm. for 9, 11, 13, 15 minutes. 

2nd Month: 

Total Exposures 12. 
At 70 cm. for 15, 17, 19, 20 minutes. 
At 65 cm. for 15, 17, 19, 20 minutes. 
At 60 cm. for 15, 17, 19, 20 minutes. 

The time and distance requirements should be observed 
in detail in order to avoid an unnecessary dermatitis and 
also to make possible a rapid increase in exposures. 

If no inconvenience or discomfort is caused to patient 
divide the time of exposure into halves — one for the an- 
terior surface of the body and one for the posterior 
surface. 

Any developing dermatitis must be treated by applica- 
tion (if bland lanolin ointment. 



338 INFANT FEEDING. 

In summarizing the curative value of light — sunlight 
and artificial — we may say with positiveness when either 
one of these or both are made available to a rachitic 
infant, the defense mechanism which has previously been 
ineffectual is put in operation. Healing is frequently 
seen, even in the absence of a change in diet, and there- 
fore, in cases so treated cannot be due to the supplying 
of the body with either calcium or phosphorus but must 
be dependent upon the raising of the potential of cellular 
activity which results in a more efficient utilization of 
the salts which are directly or indirectly concerned with 
ossification and calcification. Both methods of treatment 
result in an increase in the calcium and phosphorus con- 
tent, the hemoglobin and the number of red cells in the 
blood. 

The quartz lamp can have only a limited application 
as a therapeutic agent in general practice. The greatest 
value of the experimental researches with ultra-violet 
rays lies in the affirmation of the earlier good reports 
with heliotherapy and the relation of certain light rays 
to the normal metabolic processes of the human organism. 

If no other service is rendered they should at least 
lead to the more general recognition of the necessity of 
sunlight in the promotion of body growth and develop- 
ment. This means that good hygiene is essential to 
health and is of especial importance as a prophylactic 
measure against rickets in young infants, and an abso- 
lute essential to its cure. 

Medicinal. Although there is still much conjecture 
regarding the fundamental etiology of rickets, yet some 
pretty definite facts are known regarding the medicinal 
therapy. 

It has been repeatedly demonstrated that codliver oil 
will prevent rickets and increases the amount of calcium 
and phosphorus retention in rickets, although this action 
may be slow in the florid stage. As mentioned previ- 
ously, Howland and Park have very recently demon- 



RICKETS. 339 

strated anatomically in animals a beginning calcium de- 
posit in the bones two days after beginning the adminis- 
tration of codliver oil, and in three weeks they were able 
to demonstrate similar changes in infants by means of 
the roentgen rays. Combining phosphorus with codliver 
oil makes it more efficacious. As previously stated, 
Phemister, Wegner and Kassowitz have shown that phos- 
phorus, when administered without codliver oil, stimu- 
lates bone growth and increases the calcium deposits in 
the healthy bones of normal growing children and also 
in those rachitic. The efficacy of administering calcium 
to rachitic patients is open to much question. Most in- 
vestigators believe it is of no value except possibly in 
the case of prematures. Sufficient calcium is taken with 
the food, the trouble being rather one of- poor calcium 
retention. During convalescence, when the retention of 
calcium is extreme, calcium administration may be of 
assistance. One of the best preparations is a 10 per 
cent, tricalcium phosphate C. P. in an emulsion of cod- 
liver oil U. S. P., which makes a smooth suspension and 
is readily taken by infants. 

To be most effective codliver oil, with or without phos- 
phorus, should be started early in the artificially fed and 
also the breast-fed of races or individuals showing a 
tendency to development of rickets in the offspring. This 
is especially true of the Italian, Jewish and Negro races. 
Prematures, even when fed upon breast milk, show a 
marked tendency toward development of rickets, and 
should be placed upon codliver oil and phosphorus treat- 
ments not later than the second month. It is our custom 
to start phosphorized codliver oil, gr. }4 00 of phosphorus 
to one dram of codliver oil (0.0003 Gm. to each 4 mils), 
in small doses, by the end of the sixth week in infants 
artificially fed on heated milk mixtures. At first 0.3 to 
1.0 mil (5-15 minims) is given once or twice daily. The 
dose is rapidly increased until by the end of the third 
or fourth month, 2 to 4 mils (Vj to 1 dram) are 



340 INFANT FEEDING. 

given twice daily. Following the sixth month, 4 mils 
(1 dram) may be given two or three times daily. We 
find in most cases it is well taken when given in orange 
juice, the anti-rachitic and anti-scorbutic combination be- 
ing an excellent one in the artificially fed. The codliver 
oil therapy should be continued well into the time of 
feeding of a general diet containing more especially ani- 
mal fats, cereals and vegetables. The anemia must be 
combated with iron preparations. (See Secondary Ane- 
mia, page 414.) 

Deformities. Development of deformities of the os- 
seous system, more especially of the spine and long 
bones, can to a large extent be prevented. Infants should 
be discouraged from walking until the bones are firm. 
Head deformities can be lessened by changing the posi- 
tion in which the infant sleeps. Scoliosis may be avoided 
by preventing the child from bearing weight on the spine 
through early attempts at sitting, and improper holding 
and carrying of the infant, bowing and distortion of the 
legs by preventing crossing of the legs around the pot- 
belly. Coxa vara is due to the weight of the trunk. 
Many of the deformities can be avoided by the institu- 
tion of the proper orthopedic measures. Massage is of 
great value in strengthening the weakened muscles. 



Part VI. 

Spasmophilia. 

(Spasmophilic Diathesis. Infantile Tetany.) 



The term spasmophilic diathesis, as applied in the 
clinical sense, refers to a constitutional anomaly charac- 
terized by a general hyperexcitability and irritability of 
the nervous system. The most frequent active manifes- 
tations are general convulsions, laryngospasms, spas- 
modic apnea and carpopedal spasm. Among the latent 
manifestations are Chvostek's facial phenomenon and 
Trousseau's sign. Among the most constant findings is 
Erb's sign, the presence of hyperexcitability of the pe- 
ripheral nerves, evidenced by reaction to the galvanic 
current. 

Etiology. Heredity and familial predisposition have 
in the past been considered as important factors. In the 
light of our present knowledge as to changes in the body 
chemistry in this condition, their relationship is open to 
question ; however, it is our belief that certain types of 
infants show symptoms of an unstable nervous system 
even from birth and are therefore more likely to develop 
active clinical manifestations. To this class of cases 
belong the restless, nervous infants with a tendency to 
pylorospasms and repeated vomiting. The colicky infant 
which is often overfed to pacify it, thereby resulting 
in the development of nutritional disturbances, belongs 
to this group. They are often hypersensitive to light and 
sound, often precocious, and require much entertaining 
and soon become little tyrants, seemingly ruling the 
household. They form bad habits readily and the ut- 
most care must be taken to train them properly as to 

(341) 



342 INFANT FEEDING. 

regular habits of eating and sleeping. Added to the 
difficulties of these infants is the presence of neurotic 
parents, who often show little inclination to train them. 
We must, however, not make the error of believing that 
most infants developing spasmophilia during their in- 
fancy have this hereditary tendency. 

Spasmophilia has in the past been described as a clin- 
ical entity. In the light of more recent experimental 
and clinical facts, it must be regarded as a symptom- 
complex without a specific etiology. Tetany may be pro- 
duced experimentally by the excision of the parathyroid 
glands, by the injection into the blood stream of sodium 
phosphate or of sodium bicarbonate, by diets high in 
potassium and sodium phosphate, and by depleting the 
system of necessary salts. It occurs spontaneously in 
many cases of rickets. It may be likened to uremia in 
the course of nephritis. 

Rickets. As a result of their experiments, Shipley, 
Park, McCollum and Simmonds 1 were led to believe 
that there are two main kinds of rickets. One is charac- 
terized by a normal or nearly normal blood calcium and 
a low blood phosphorus (low phosphorus rickets) ; the 
other by a normal or nearly normal blood phosphorus 
but a low blood calcium (low calcium rickets). 

If the hypothesis just stated is correct, they believe 
the relation of tetany to rickets would appear to be as 
follows: Tetany is essentially an expression on the part 
of the nervous tissues of an insufficiency of the calcium 
ion ; rickets is essentially an expression on the part of 
the skeleton of disturbed relations between the calcium 
and phosphate ions of the body fluids. Tetany is fre- 
quently associated with rickets because rickets is a dis- 
ease in which the calcium ion in the body tissues and fluids 
is subject to variations. Tetany may occur independent of 
manifest rickets. Since tetany may occur with the low 



1 Shipley, Park, McCollum and Simmonds : Am. Jour. Dis. of 
Children, v, 23, p. 91, 1922. 



SPASMOPHILIA. 343 

phosphorus form of rickets, it does not serve to mark off 
one form of rickets from the other. Tetany, however, is 
essentially, associated with the low calcium form of rickets 
and, for all practical purposes, the low calcium form of 
rickets is the rickets of tetany. 

While occasionally cases are seen in which clinical evi- 
dence of rickets is not demonstrable, these cases are on 
the whole exceptional. On the contrary, many cases of 
rickets, even very severe types, exist in which tetany 
does not supervene. 

Diet. The feeding history, with its associated nutri- 
tional disturbances, is of great importance in the inter- 
pretation of the clinical manifestations. It is but rarely 
seen in the breast-fed, and most frequently seen in the 
infants fed upon proprietary foods, more particularly 
those who have had repeated changes in their diet. Over- 
feeding with a diet composed almost exclusively of cow's 
milk frequently aggravates the condition and may, in 
latent cases, precipitate the active manifestations in all 
probability due to a disturbance of the salt metabolism 
by the whey content of the cow's milk. One of the most 
striking phenomena in the treatment of these cases is 
the rapid disappearance of all manifest signs when the 
infants are placed upon breast milk, with the reappear- 
ance upon the addition of relative excesses of whey or 
large quantities of cow's milk. 

Nutritional disturbances and various errors of diet 
often predispose to attacks. These errors of diet may 
be overfeeding (quantitative) or improperly propor- 
tioned diets (qualitative), which sooner or later result 
in acute nutritional disturbances which precipitate the 
clinical manifestations. 

Premature infants evidence a marked predisposition, 
but in the breast-fed receiving sufficient food, the mani- 
fest symptoms occur exceptionally. Convulsions, when 
present in the breast-fed, usually follow acute nutritional 
disturbances and infections. Not uncommonly the mere 



344 INFANT FEEDING. 

changing to cow's milk precipitates convulsions. Even 
in premature infants fed on human milk the electrical 
irritability often is such that C.O.C. is less than 5 milli- 
amperes at the age of 6 to 10 weeks. This electric hyper- 
irritability is most frequently seen during the fourth 
month in prematures and gradually disappears during 
the fifth to sixth month. — Yllpo. 1 

The early development of rickets in the premature 
may in greater part account for the early development 
of spasmophilia in these infants. 

Acute Infection. Some form of infection, although 
slight, is frequently the precipitating factor of the acute 
manifestations. Reinfection will aggravate the symp- 
toms or they may precipitate fresh attacks in healed 
cases. 

Vitamincs. The work of Mysenburg 2 tends to dis- 
prove any relationship between the vitamines and spas- 
mophilia. 

Age. The active manifestations are usually evidenced 
between the sixth month and second year in full-term 
infants, while in the premature they may be seen as 
early as the second to the fourth month. 

Season. The most active manifestations, such as con- 
vulsions, laryngeal and carpopedal spasms are most com- 
monly seen during the winter and early spring months. 
The season of highest instance in most cases corresponds 
with that in which rickets becomes most manifest. Poor 
hygiene, lack of sunlight, secondary infections in the 
infant, and, in all probability, the diet of the mother, 
or that of the cows, are all contributing factors. The 
convulsions seen with summer diarrhea are more often 
toxic or infectious in origin. 

Pathogenesis, Several theories have been advanced. 
All of these have as a basis some fundamental disturb- 



1 Yllpo : Zeitschr. f. Kinderh., xxiv, 1919, 1. 

2 Mysenburg: Am. Jour. Dis. of Children, V. 20, p. 206, Sept. 
1920. 



SPASMOPHILIA. 345 

ance in metabolism. The most generally accepted has 
been based on experimental and clinical evidence of de- 
creased calcium retention. More recently considerable 
data has been produced seemingly pointing to increased 
retention of the alkali phosphates (K and Na), with a 
secondary diminution of Ca salts as precipitating factors. 

Kramer and Howland found that in children suffering 
from rickets alone, the phosphorus of the blood serum is 
low, and the calcium not far removed from the normal ; 
in children suffering from manifest tetany complicating 
rickets, on the other hand, the calcium is low but the 
phosphorus not far removed from normal. 

Calcium Metabolism. A calcium deficiency in the 
tissues has been demonstrated by numerous investigators, 
more especially in the brain and blood. The earlier in- 
vestigations on the blood, by Howland and Marriott, 1 
have more recently been confirmed by Kramer, Tisdall 
and Howland. 2 They found the calcium of the blood 
serum to be low in tetany, averaging 5.6 milligrams per 
100 cubic centimeters of serum, about half the normal. 
Their lowest estimation was 3.5 milligrams per 100 cubic 
centimeters of serum. The average normal amount of 
calcium per 100 cubic centimeters in their cases was be- 
tween 10 and 11 milligrams. The latter group of 
workers found the concentration of the sodium, potas- 
sium and magnesium in the serum of the patients with 
tetany is essentially normal. On the other hand the 
concentration of the calcium is regularly lowered. Ob- 
viously the important factor in the increasing irritability 
of the neuromuscular mechanism in infantile tetany is 
the decrease in the calcium concentration. The stimu- 
lating effect of the sodium and potassium salts is un- 
opposed by the inhibitory effect of calcium. 



1 Rowland and Marriott: Quarterly Jour. Med., xi, 1917, 18. 
289. 

-Kramer, Tisdall and Howland: Am. Jour. Dis. of Children, 
xxii, 431, 1921. 



346 INFANT FEEDING. 

The relation of calcium to the symptoms of spasmo- 
philia has been studied extensively, especially its influ- 
ence on the electric excitability. Physiologists have 
shown that certain mineral ions exert a specific effect on 
muscle nerve irritability. Rosenstern 1 and Sedgwick- 
reduced the electric irritability in spasmophilic infants 
by administering large doses of calcium by mouth. 
Loeb's 3 findings indicate that Na and K increase the 
threshold for excitation, while Ca and Mg tend to de- 
crease this. This muscle nerve irritability is the func- 

" Ca plus Mg , . . . „ . . 

tion of the quotient as designated by Reiss. 4 

Na plus K, 

Holt 5 has demonstrated that in the course of diarrheal 
attacks there is a much greater loss of Na and K than Ca 
and Mg in the stools. Diuresis and catharsis often cause 
an improvement in the spasmophilic symptoms. 

Phosphorus Metabolism. Howland and Kramer 6 have 
determined the inorganic phosphate of the serum in a 
large series of normal infants. They found the con- 
centration to average 5.4 milligrams per hundred cubic 
centimeters, with a minimum of 4 milligrams and a 
maximum of 7.1 milligrams, the higher values being 
usually found in the serum of exclusively breast-fed 
children. A determination of the inorganic phosphorus 
of the serum in infantile tetany revealed that in about 
half the cases the phosphorus concentration was within 
normal limits or slightly above normal. This is in marked 
contrast with cases of uncomplicated rickets, i.e., with- 
out tetany, in which they found a much reduced inor- 
ganic phosphate serum content. In no case did they 



1 Rosenstern : Jahrb. f. Kinderh. lxxii, 1910, 154. 

2 Sedgwick, J. P.: St. Paul, Med. Jour., 1912, Vol. xiv, 497, 
519. 

3 Loeb, J. : Oppenheimer's Handbuch der Biochemie. 

4 Reiss : Zeitschr. f. Kinderh., 1911, iii, 1. 

5 Holt, Courtney and Fales : Am. Jour. Dis. of Children, 1915, 
ix, 213. 

6 Howland, J. and Kramer, B. : Am. Jour. Dis. of Children, 
xxii, 105, 1921. 



SPASMOPHILIA. 347 

find a marked increase in the inorganic phosphorus con- 
centration above the normal level. On the whole, the 
inorganic phosphorus of the serum showed a consider- 
able variation. In a number of cases there was a 
relative increase when compared with the calcium con- 
centration. The significance of this relatively high phos- 
phate content in the presence of decreased calcium in 
cases of rickets complicated by tetany is as yet not clear. 
They state that an increase in the inorganic phosphorus 
of the serum alone, however, does not seem to be re- 
sponsible for infantile tetany. 

Binger 1 was able to produce tetany by the intravenous 
injection of orthophosphates. He found that not in- 
frequently in conditions with a calcium deficiency alone 
tetany was absent. These authors state that the reduc- 
tion of calcium alone is not sufficient to bring about 
the symptoms of tetany unless certain other conditions 
are satisfied. The question as to the nature of such 
associated findings must be answered by further study. 

Jeppsson and Klercker, 2 in a series of experiments, 
found that by feeding of 0.20 Gms. of P 2 5 , in the form 
of K or Na diorthophosphate per kilogram body weight, 
to the normal infant, and 0.10 to spasmophilic infants, 
they were able to produce symptoms similar to those 
seen in active spasmophilia or to activate the manifesta- 
tions in latent cases (0.20 gram of P 2 5 represents 
in alkali diorthophosphates 0.27 Gms. of K 2 and 
0.18 Gms. of Na 2 or 0.49 Gms. of K 2 HP0 4 and 0.39 
Gms. of Na 2 HP0 4 ). When using the potassium salts 
at times these results were manifested in a few hours. 
With the sodium salts larger quantities were required 
and often the symptoms were not evident until after 
two or three days of treatment. 

They believe that most spasmophilic children receive 
an excess of alkali phosphates in their diets, more espe- 



1 Binger : Jour. Pharmacol, and Exper. Therap. 10, 1917, 105. 
-Jeppsson and Klercker: Zeitschr. f. Kinderh., 1921, Vol. 28, 71. 



348 IX FA XT FEEDING. 

daily during the first and second year, with the excep- 
tion of the first few months of life, and that the alkali 
phosphates play a role in the genesis of tetany. 1 

The parathyroid theory is to a large extent based upon 
the fact that the physiologic and chemical findings in 
spasmophilia, in infants, and parathyroid tetany, in ani- 
mals, are nearly identical. The histological evidence is 
conflicting and for the most part negative. Accidental 
removal of the parathyroid gland in humans and experi- 
mental excision of these glands in animals, have both 
resulted in a tetany that resembles in its clinical mani- 
festations the spasmophilia of infants. Following the 
animal experiments Howland and Marriott 2 have demon- 
strated a diminution in the calcium content of the blood. 
These findings have been verified by MacCallum and 
his co-workers, 3 who also found a decreased calcium 
content in the brain and an increased excretion. They 
believe that the parathyroid gland regulates calcium 
metabolism and that failure in its secretion results in 
a lessened retention. Greenwald, 4 in his experimental 
studies, found that the phosphorus excretion in the urine 
of his animals was greatly decreased, to as low as 8 per 
cent, of the normal, shortly after operation but after 
development of tetany it increased rapidly, occasionally 
to an amount in excess of the preoperative content. He 
also found an increase of the phosphorus content of the 
blood before the appearance of tetany. There was also 
a sodium and potassium retention. He believes that fol- 



1 J. K. Calvin and M. P. Borowski : Amer. Jour. Dis. of Child- 
ren, 23, 1922, instituted a series of investigations on our service 
at Cook County Hospital to corroborate the Jeppsson and Klerc- 
ker findings. They were unable to duplicate these results by the 
use of the dosage of potassium or sodium diorthophosphates re- 
commended by these investigations. The observations were made 
on rachitic infants varying from 6 to 18 months of age, some of 
whom had recently recovered from actively manifested spasmo- 

philias. 

2 Howland and Marriott : Trans. Amer. Ped. Soc, 28, 200, 1916. 

3 MacCallum and Voegtlein : Jour. Exper. Med., xi, 118, 1909. 
^ Greenwald, J.: Jour. Biol. Chem., Vol. 14, 370, 1913. 



SPASMOPHILIA. 349 

lowing the extirpation of the parathyroid there is a de- 
creased excretion through the kidneys and an abnormal 
retention in the tissues of the alkali phosphates, which 
is followed by a decreased retention and an increased 
excretion through the kidneys as soon as the spasms 
develop. 

There is, however, great question as to the relation- 
ship of parathyroid dysfunction and tetany in the infant. 
Pathological studies lead us to believe that parathyroid 
lesions in infantile tetany are the great exception. Para- 
thyroid lesions have been described in patients who have 
shown no evidences during life of the pathognomonic 
findings of tetany. 

In summarizing the pathogenesis we may state that a 
diminution of the calcium salts in all probability is the 
most important factor in the development of this con- 
dition. However, the possibility of an absolute or rela- 
tive excess of the phosphates, especially the sodium and 
potassium salts, playing an important role cannot be over- 
looked. Abnormal ratios in the body salts, as in rickets, 
play an important role. The relationship of disturbances 
in parathyroid functions to the diminution of calcium 
tissue content must be made the subject of further study 
before its importance can be fixed. Infections are the 
most frequent factor in precipitating manifest symp- 
toms in the latent cases. The seasonal incidence empha- 
sizes the importance of the relationship between active 
rickets, infections and spasmophilia. 

Symptoms. The term spasmophilic diathesis is used 
in a clinical sense to cover a symptom complex, com- 
prising a group of signs, any one or all of which are 
pathognomonic of the condition. 

They consist of two groups, which are best described 
as latent and active. Cases presenting all of the signs 
to be described are the exception and in most instances 
the diagnosis will be made in the presence of one or 
more of them. 



350 



1XFAXT FEEDING. 



The latent signs are more apparent than the active 
ones, and in their most frequent sequence are : 

Erb's sign, better designated as increased electric 
hyperexcitability ; Chvostck's facial phenomenon, and 
Trousseau's sign. Of the active signs generalized con- 
vulsions are the most frequently seen, while laryngo- 
spasm, spastic apnea and carpopedal spasms are of less 




Fig. 18. — Spasmophilia — Carpo-pedal spasm. This infant 
was of the neuropathic type from birth and also presents 
a marked case of exudative diathesis. 



frequent occurrence. It, therefore, becomes obvious 
that many cases of spasmophilia would be overlooked 
were it not for the uncovering of the latent manifesta- 
tions during the course of a routine physical examina- 
tion. On the other hand, the interpretations of convul- 
sions must be dependent to a large extent upon a careful 
study of the clinical history. Otherwise, cases of spas- 



SPASMOPHILIA. 351 

mophilia will be overlooked or a diagnosis of this con- 
dition made in cases due to other causative factors. 

Erb's Sign (Increased Electrical Irritability). The 
test is made with a galvanic current, and for this pur- 
pose a small battery made up of dry cells answers the 
purpose best for the finer tests. However, there are 
batteries with transformer attachments which can be 
used with ordinary lighting current. A large, flat elec- 
trode (5 cms.) is placed on the chest or upper abdomen 
of the infant and a small Stintzing electrode, 1 or 2 cms. 
in diameter, is placed over the median nerve, just below 
the elbow, or over the peroneal nerve in the outer part 
of the popliteal space near the head of the fibula. For 
the purpose of making the test the opening contractions 
are used. 1 The CO. C. is usually first used because of 
its being the easier of the two opening contractions to 
demonstrate, due to the fact that in normal infants under 
2 years of age, approximately nine M. A. are required 
to obtain a reaction. After completing this test the pole 
should be reversed and the A. O. C. tested. In making 
these tests the C. C. C. is of little value and the A. C. C. 
is only used for comparison with the A. O. C. The test, 
whether studying the C. O. C. or A. O. C, should always 
be begun with a current of sufficient strength to produce 
a contraction of the muscles of the palm and fingers, 
when the median nerve is used, and the muscles of the 
dorsal surface of the foot and toes when the peroneal 
nerve is used. (Figs. 19 a, b.) 

The average normal reaction, under 2 years of age, 

will approximate the following : 

C.C.C. A. C. C. A. O. C. C. O. C. 

2 3 5 9 

1 For purposes of convenience the following terms have been 
abbreviated : 

Cathodal closing contraction C. C. C. 

Anodal closing contraction A. C. C. 

Anodal opening contraction A. O. C. 

Cathodal opening contraction C. O. C. 

Milliamperes M. A. 



352 



INFANT FEEDING. 



In infants the following electrical reactions are pathog- 
nomonic of tetany, in the absence of brain lesions. 

C. O. C. under 5 M. A. 

A. O. C. with less current than that causing an A. C. C. 
and under 5 M. A. up to the end of the second year. 
After this age there is a normal tendency for the A. O. C. 
to appear with less than 5 M. A. 

A C. O. C. with less than 2 M. A. is indicative of the 




Fig. 19. — Spasmophilia. A. Carpal Spasm. B. Pedal Spasm. 



appearance of early convulsions and should always be 
considered as indication for active treatment. 

Chvostek's facial sign depends upon the hyperexcita- 
bility of the facial nerve. Tapping lightly with the 
finger along the course of the nerve, midway between 
the zygoma and the angle of the mouth, results in a con- 
traction of the ala of the nostril, angle of the mouth, and 
in most cases the inner canthus of the eye and the eye- 
brows. The appearance of a Chvostek phenomenon 
under 2 years, in the absence of birth trauma, indicates 
tetany. After 3 years the Chvostek phenomenon is not 
infrequently found in milder grades, in apparently nor- 
mal children. 



SPASMOPHILIA. 



353 



Trousseau's sign, elicited by moderately compressing 
the nerves and vessels of the arm midway between the 
elbow and shoulder by the hand or an elastic constrictor, 
is evidenced when present by the development of a 
carpal spasm (obstetrical hand). 

Active Signs. Carpopcdal spasms or arthrogryposis 




Fig. 20.— Spasmophilia. Trousseau's sign. (Bilateral.) 

(state of tetany), are seen clinically as tonic spasms of 
the hands and feet. The fingers are usually flexed at 
the metacarpophalangeal joints and the phalanges ex- 
tended ; the thumbs are adducted almost to the little 
finger ; the wrist is flexed at an acute angle, and the 
whole hand drawn somewhat to the ulnar side. If the 
spasm is very marked no motion is allowed at the wrist, 
but movements at the elbow and shoulder are usually 

23 



354 INFANT FEEDING. 

normal. The feet are strongly extended, sometimes 
in the position of typical equino-varus and the first 
phalanges of the toes are flexed. If these conditions 
persist for a long time, edema of the dorsal surfaces 
of both hands and feet will develop. The clonic con- 
tractions at times remain for hours, and even days, and 
are evidently quite painful. 

Convulsions (Eclampsia). Evidenced by loss of con- 
sciousness, spasms of the face and extremities at first 
tonic, later clonic. They usually last only a few min- 
utes — may or may not recur. In exceptional cases a 
"status eclampticus" develops. More commonly, how- 
ever, in the milder types the infant will recover from 
the individual attack quickly and without seeming after- 
effects, thereby resembling the petit-mal attacks of epi- 
lepsy. Only in the severest forms do they resemble the 
grand-mal attacks and only rarely is coma seen following 
the seizure. Due to the fact that spasmophilia is most 
frequently seen during the active period of early denti- 
tion and that many of the cases show delayed dentition 
the laity are inclined to ascribe teething erroneously as 
a cause. 

Laryngismus Stridulus. (Inspiratory laryngospasm.) 
May occur without provocation or following crying or 
fright. There is an inspiratory crow, due to spasmodic 
closure of the larynx, associated with cyanosis and it 
may be followed by convulsions. The condition may 
persist over a period of several weeks or until proper 
treatment is instituted. 

Spastic apnea or expiratory apnea are usually de- 
scribed as "holding breath spells" and are usually mild 
and transitory. They may result in cardiac death. 

Course. The acute symptoms may last from a few 
days to several weeks. It varies in most cases directly 
with the treatment. Occasionally a persistent type is 
met with. Rickets, nutritional disturbances and infec- 
tions must be overcome. 



SPASMOPHILIA. 355 

Prognosis. Acute Attack. It should always be 
guarded, as it depends upon the underlying conditions 
which account for the symptoms. Convulsions should 
always be considered as symptoms of grave importance. 
The presence of thymus enlargement has a direct influ- 
ence on the mortality rate. 

Pertussis should be considered a serious complication. 
In the majority of cases the prognosis is, on the whole, 
good. 

After-life. While many of these children show no 
after-effects, a considerable number suffer from nerv- 
ous manifestations in later life, as headaches, pavor noc- 
turnis, enuresis, tic, stuttering, etc. Others show men- 
tal retardation. 

Treatment. Dietetic. Latent spasmophilia should be 
treated prophylactically to prevent the development of 
the manifest symptoms. As spasmophilia is relatively 
rare in breast-fed infants, the latent spasmophilic should, 
by preference, be fed human milk either from its mother 
or a wet-nurse. In cases in which the condition does 
develop in breast-fed babies, it often disappears if the 
infant is given breast milk from another source or a 
mixed diet. When this is impossible the cow's milk 
should be limited to a pint a day or it may be replaced 
by albumin (eiweiss) milk which has a low whey con- 
tent. A cereal and vegetable diet should be instituted 
whenever the infant's age permits. Fruit juices are also 
essential. It is often well to keep the diet as small in 
quantity as is compatible with progress in the child. A 
temporary stationary weight should not be considered as 
cause for concern. Sodium and potassium salts should 
be avoided. A certain group of artificially fed infants 
will do better when cow's milk, in all forms, is greatly 
reduced. If the latent phenomena recur when cow's 
milk is again increased, these infants should be fed hu- 
man milk for a considerable time. In snch cases a mixed 
carbohydrate diet, consisting of cereals and sugars, to- 



356 JXFAXT FEEDING. 

gether with vegetable purees and fruit juices, should 
be instituted whenever possible. 

They should not be kept for too long a time on a 
strict cereal diet, due to the danger of development of 
"flour injury." 

Medicinal. Codliver oil alone, or combined with phos- 
phorus, offers the best form of medicinal treatment 
during the latent stage, however in the presence of ac- 
tive manifestations they must be supplemented by other 
forms of treatment. 



Fig. 21. — Spasmophilia — Pathological fractures of radius 
and ulna with angular deformities following carpal spasm. 
(Bilateral.) 

The calcium salts in the form of chloride, lactate or 
bromide, may be used to advantage both during the 
active and latent stages. The calcium salts should al- 
ways be prescribed in solution to prevent injury to the 
mucous membrane. Calcium lactate or calcium chloride 
may be administered in 0.5-1. Gm., three or four times 
daily, or calcium bromide in one-half these amounts. 
They are best administered in the food mixtures. 

Convulsions. An initial dose of castor oil or magma 
magnesia is a valuable adjunct to the further treatment 
in the absence of marked gastro-intestinal irritation. A 
short period of starvation diet, consisting of tea and 



SPASMOPHILIA. 357 

saccharine, should be followed by human milk where 
possible. When it is necessary to feed artificially the 
infant should be kept for twenty-four hours following 
the short starvation period on cereal gruel plus sugar, 
this to be followed by low milk and carbohydrate meals 
or albumen milk. .Following this the previously recom- 
mended dietetic treatment may be instituted. It may be 
necessary to control the active manifestations by bro- 
mides per mouth and chloral hydrate per rectum, and 
when the temperature is high saline enemata, packs, 
sponging and baths are indicated. In the presence of 
repeated convulsions we have frequently seen excellent 
results following the administration of 10 cubic centi- 
meters of an 8 per cent, solution of magnesium sulphate, 
hypodermically daily for one, two, or three days. 

Further treatment should include the secondary ane- 
mia and not infrequently a change of climate is of ad- 
vantage so that an outdoor life can be lived. Under all 
circumstances a good hygienic and dietetic regime should 
be instituted. Heliotherapy is of especial importance in 
all cases developing in the course of rickets. 

Efforts should be directed toward the prevention of 
all respiratory infections, more especially during the 
winter and spring months. 

Parathyroid feeding has shown no results. 



Part VII. 

Scurvy. 

(Scorbutus, Barlow's Disease.) 



Scurvy is primarily a deficiency disease, due to insuf- 
ficiency of the antiscorbutic vitamine. The disease fol- 
lows improper diet. The chief pathological changes are 
noted in the blood vessels and bones. There are two 
distinct clinical types: the acute and the subacute. The 
acute florid type presents the classical picture of mal- 
nutrition, secondary anemia and hyperesthesia. Skin, 
mucous and serous membrane, visceral and subperios- 
teal hemorrhages develop. Subacute or latent scurvy is 
the most common form of the disorder and is character- 
ized by an insidious onset of weeks or months, evidenced 
by lack of gain or loss in weight, anorexia, irritability 
and secondary anemia. Later, hemorrhages may occur. 
This type is more frequently overlooked, as it does not 
manifest pronounced symptoms. The general improve- 
ment of these symptoms following antiscorbutic treat- 
ment confirms the diagnosis. 

Etiology. Congenital and inherited disease appar- 
ently play no part as a causative factor. It occurs most 
frequently between the ages of 6 and 15 months, half 
of the cases occurring between the seventh and tenth 
months, although occasional cases have been reported 
in babies under one month old. The age of development 
of the disease depends upon the length of time that a 
diet containing an insufficient amount of antiscorbutic 
has been fed; even in a decidedly deficient diet a con- 
siderable time is necessary before the disease becomes 
clinically manifest. The age at which it most frequently 
(358) 



SCURVY. 359 

appears is that in which artificial feeding on cow's milk 
and dextrinized cereal diet, or other diets low in anti- 
scorbutics, are most commonly required. This age might 
be referred to as the period of limited diet. Spontane- 
ous cure in undiagnosed cases is the rule when the in- 
fants reach the age of fresh cereal, fruit and vegetable 
diet. 

Scurvy is rare in the breast-fed infants, but does oc- 
cur. The health and especially the diet of the mother 
are important predisposing factors. McCollum and 
Simmonds 1 have shown that in lactating rats the vari- 
ous vitamines cannot be synthesized and the content in 
the milk depends largely upon the amount eaten with 
the food. Hart, Steenbock and Ellis, 2 and Hess, Unger 
and Supplee, 3 have also shown this to be true of cows 
fed upon a diet deficient in antiscorbutic vitamine. Even 
when the lactating mother receives a diet deficient in 
vitamines, the cellular substance of the mother's body 
contains some, which the catabolic processes liber- 
ate, so that the milk cannot be entirely lacking in 
vitamines although the content may be too small to pre- 
vent scurvy. Secondly, even though the mother's diet 
is rich in vitamines, if she produces only a small quan- 
tity of milk, the amount of antiscorbutic vitamine will 
naturally be insufficient and thus predispose to scurvy 
in the exclusively breast-fed. Rickets, other diseases 
affecting the infant's metabolism, and infection may all 
predispose to scurvy, in the breast-fed as well as in 
bottle-fed infants. Infection as a precipitating factor 
will be discussed more fully later. 

Most of the scurvy cases develop in artificially fed in- 
fants. As in the breast-fed, the absence of some vital 



1 McCollum, E. V. and Simmonds, N. : Amer. Jour, of Phys., 
1918, 46, 275. McCollum, E. V., Simmonds, N. and Pitz, W. : 
four. Biol. Chem., 1916, 27, 33. 

- Mart, E. B., Steenbock, H. and Ellis, N. R. : Jour. Biol. Chem , 
1920, 42, 3H3. 

'■'' 1 less, A., Unger, L. and Supplee : Jour. Biol. Chem., 1920, 
4N, _'_"'. 



360 INFANT FEEDING. 

element in the food is the causative factor. Starvation 
in itself will not cause the disease, providing enough 
antiscorbutic substance is given. The time factor is very 
important in that diets low in antiscorbutic content must 
be fed over a prolonged period to cause the disease. 
Scurvy occurs most frequently in infants fed on pro- 
prietary foods. These are composed largely of dex- 
trinized cereals, they are subjected to a long process of 
heating and although milk is added, the quantities are 
insufficient to meet the antiscorbutic needs. In addition, 
the milk used is usually subjected to prolonged or ex- 
cessive heating, and in large cities where pasteurization 
is compulsory, frequently to a second heating and con- 
sequent ageing. Scurvy is much rarer where milk is 
the principal article of diet. Cow's milk in itself is 
relatively low in antiscorbutic. 1 2 It is estimated that 
a pint of raw, fresh cow's milk daily contains enough 
antiscorbutic to protect an infant from scurvy, when 
the animal from which it is obtained has been on a well- 
balanced diet. 3 The winter diet of cattle which until 
the introduction of ensilage was composed largely of 
grains and hay, resulted in the production of a milk 
with a lessened antiscorbutic content. This may have 
been a predisposing factor in the reported seasonal ten- 
dency of the disease. High dilutions of milk with a 
lessened quantitative content is another factor; this is 
comparable to the scant lactation in the breast-fed. 

Ageing appears to be a more important factor than 
the heating of milk as far as the reduction or destruc- 
tion of the antiscorbutic element is concerned. Hess 4 
states that boiled milk is less liable to induce scurvy 



i Moore, J. J. and Jackson, L. : Jour. A. M. A., 1916. 

2 Chick, H. and Hume, M. : Lancet, 1918, i, 1, Barnes and 
Hume. M.: Lancet, 1919, ii, 323. Cohen and Mendel: Jour. Biol. 
Chem., 1918, 35, 425. 

3 Hess, A., and Unger, L. : Amer. Jour. Dis. of Children, 1919, 
17, 221. 

4 Hess, A. : Amer. Jour. Dis. of Children, 1917, 14, 337. 



SCURVY. 361 

than is pasteurized milk, due, he believes, to the fact 
that the long-continued exposure to heat in pasteuriza- 
tion (145° F. for 30 minutes) has a more destructive 
action than a short boiling (212° F. for a few minutes). 
His conclusions lead one to believe that he considers 
two factors of prime importance : first, ageing in itself, 
and, second, ageing plus the added factor of heating to 
a definite degree. He considers the possibility of oxida- 
tion during the period of ageing as being the destructive 
factor. 

Hess 1 further states that when fresh cow's milk is 
dried in a few seconds at a temperature of 240° F. 
(116° C), little of its antiscorbutic property is lost if 
kept hermetically sealed to prevent oxidation. We have 
confirmed this by feeding guinea pigs dried milk pre- 
pared by the Just Hatmaker process. 2 It must, however, 
be fed in sufficient quantities, which is best accomplished 
by feeding a concentrated mixture. The exact value of 
dried milk as a complete diet for babies is open to ques- 
tion, in the light of our personal experiences. 

While scurvy occurs occasionally in breast-fed in- 
fants and in those fed on raw cow's milk, it is seen more 
frequently in infants fed on boiled, pasteurized and 
condensed milk, and in these cases, as previously stated, 
two factors are important — prolonged heating and age- 
ing of the foods, either before or after heating. The 
same factors are important in the heating of proprie- 
tary cereal foods plus limited quantities of cow's milk. 
In these diets the vitamines have been destroyed or 
made less active in the cereals and are insufficient in 
the milk to meet the needs of the infant. A predispos- 
ing constitutional factor in the individual is not to be 
overlooked, and probably accounts for the precipitation 
of the disease in some infants while others escape on 
the same diet. 



i Hess, A., and Unger, L. : Jour. Biol. Chem., 1919, 38, 293. 
2 Moore, J. J., Hess, J. H., and Calvin, J. : Unpublished ex- 
periments. 



362 INFAXT FEEDING. 

Previous diseases in the artificially fed, such as rick- 
ets, marasmus and other disturbances of metabolism, 
probably play a role in predisposing to scurvy, because 
all of these conditions presuppose a poorly regulated diet, 
both quantitatively and qualitatively, which diet would 
probably also be unbalanced in its antiscorbutic element. 

The relation of infections to scurvy has been widely 
discussed recently. Epidemics of scurvy have been re- 
corded in babies' institutions. These probably were 
cases of latent or subacute scurvy, in which the acute 
florid type was precipitated by a superimposed paren- 
teral infection. Further, experience has led us to believe 
that scurvy predisposes to intercurrent infection, more 
especially of the skin, respiratory and gastro-intestinal 
tracts. These secondary bacterial infections may cause 
hemorrhagic lesions and the symptoms of the intestinal 
and infectious disorders become so intertwined as to be 
indistinguishable. 

Summarizing, we believe the evidence of a specific 
organism as a factor is absolutely inconclusive. How- 
ever, parenteral infections may precipitate the develop- 
ment of scurvy, or be a factor in causing a latent case 
to become active. Enteral infections, by preventing nor- 
mal metabolic exchange, may pave the way for the de- 
velopment of scurvy, as may also be the case in the 
absorption of abnormal intestinal substances which are 
the end-products of bacterial activity. 

The relation of vitamines to these so-called deficiency 
diseases is a much discussed subject and much experi- 
mental work has been undertaken in this direction. 
Funk, 1 in 1911, first called attention to this relationship. 
He classed beriberi, scurvy, pellagra, and rickets as de- 
ficiency diseases. 

The beading of the ribs, formerly thought so charac- 
teristic of rickets, may also occur in uncomplicated cases 



iFunk, C. : Lancet, London, 1911, ii, 1266. Die Vitamine, Wies- 
baden, 1914. 



SCURVY. 363 

of scurvy in infants, and very often the rosary quickly 
becomes less or disappears when orange juice or other 
antiscorbutic food is given. This beading has been ob- 
served in scorbutic guinea pigs by Moore and Jackson, 1 
and others. (Fig- 22.) It is truly scorbutic, as it 
shows the various microscopic appearances of scurvy. 
Beading of the ribs may also come about as the result 
of a lack of the water-soluble vitamine, although less 




Fig. 22. — Scurvy in guinea-pig showing beading at the 
costochondral junctions. {Jackson and Moore.) 

frequently than in scurvy. This latter type of beading 
decreases in size when the water-soluble element is 
added to the diet. — Hess. 2 Andrews 3 states that in 
eighteen cases of beriberi he encountered three instances 
of beading of the ribs at necropsy, although he had 
never seen rickets at necropsy in the Philippines. Darl- 



1 Moore, J. J. and Jackson, L. : Jour. A. M. A., 1916, 67, 1931. 

2 Hess, A. and Ungcr, L. : Jour. A. M. A. 1920, 74, 217. 

3 Andrews, W. L, : Philippine Jour, of Science, 1912, 7, 67. 



364 INFANT FEEDING. 

ing 1 states that scurvy resembles beriberi in the nervous 
involvement, both having increased knee-jerks, a much 
increased cardio-respiratory rate, and general and optic 
nerve edema. Pathologically both show enlargement of 
the heart and fatty degeneration of the heart muscle and 
vagus. Nichols 2 states that in the tropics adult cases 
of scurvy often resemble pellagra and that they have 
much symptomatology in common. 

Classification and Distribution of Vitamincs. McCol- 
lum and Davis 3 have demonstrated two vitamines, fat- 
soluble A and water-soluble B (antineur-itic). Most in- 
vestigators now agree that there is at least a third one, 
namely: water-soluble C (antiscorbutic). These sub- 
stances are constituents of the cells of both animal and 
plant tissues, and the content runs parallel to the cellu- 
lar element of the foodstuffs. Although all natural food- 
stuffs contain certain amounts of these indispensable 
components of the diet, there is a great variation in the 
relative and absolute amounts contained. Thus, the best 
sources of fat-soluble A are animal fats, egg yolk fats, 
fish oils, milk fat and the leaves of plants; water-soluble 
B in yeast, fruit juices, vegetables and grain embryos. 
The leafy vegetables and those growing above the ground, 
such as tomatoes and celery, contain it in larger pro- 
portions than the root vegetables, such as potatoes, car- 
rots and turnips; zvatcr-solublc C, the antiscorbutic ele- 
ment, is found in practically all fresh animal and vege- 
table tissues and fruits but to a much greater extent in 
the latter. It is present in actively living cells, so that 
in general those vegetable tissues which contain rela- 
tively large numbers of actively respiring cells (leafy 
vegetables), are richer in antiscorbutic power than are 
the roots or tubers. This generalization is not without 



i Darling, S. T. : Jour. A. M. A., 1914, 63, 1290. 
- Nichols, L. : Jour, of Tropical Med., 1919, 22, 21. 
3 McCollum, E. V., and Davis, N. : Jour. Biol. Chem., 1915, 
23, 181. 



SCURVY. 365 

exception. Different vegetables and fruits vary greatly 
in their antiscorbutic potency. They differ widely also 
in the extent to which their antiscorbutic value will de- 
teriorate under certain physical and chemical conditions 
(drying, alkalinizing, etc.). From the above statement 
it is apparent that the antiscorbutic potency of food- 
stuffs varies directly with the quantity contained. 

Value of Various Foodstuffs. Considerable research 
has been conducted in the past few years to determine 
the antiscorbutic value of various foodstuffs, and the 
effect of ageing, drying, heating and alkalinizing them. 

Milk contains a moderate amount of all three vita- 
mines. Milk alone is a complete food for a number 
of animal species, i.e., rats and swine. However, guinea 
pigs suffer from scurvy on a diet of oats and milk, even 
when raw and fresh, according to McCollum 1 and 
Moore, 2 which is a difficult fact to explain on a vita- 
mine hypothesis, except that the amount of milk which 
a guinea pig will drink of its own accord does not con- 
tain a sufficient amount of antiscorbutic to protect it 
from scurvy. Barnes and Hume 3 state that 100 to 150 
cubic centimeters- daily of raw cow's milk will prevent 
scurvy in a guinea pig, but that such a large daily intake 
of milk causes digestive disturbances. Hess 4 states that 
80 cubic centimeters of fresh, raw cow's milk will pre- 
vent the appearance of scurvy in guinea pigs. 

Many fruits are excellent antiscorbutics. Orange 
juice is one of the best antiscorbutic substances. It also 
contains the water-soluble B vitamine, which is essential 
for growth and thus markedly stimulates growth. It 
should be fed in considerable quantities, varying from 
15 to 45 cubic centimeters daily for the latter effect. 5 



i McCollum, E. V. and Pitz, W. : Jour. Biol. Chem., 1917, 31, 
229. 

- Moore, J. J. and Jackson, L. : Jour. Inf. Dis., 1916, 19, 478. 
:: Barnes, K. and Hume, M. : Lancet, London, 1919, 11, 323. 
* 1 less, A. and Unger, L. : Ibid. 

5 Byfield, A., and Daniels, A. L. : Am. Jour. Dis. of Children, 
1920, 19, 349. 



366 INFANT FEEDING. 

Orange juice is still efficient after ten minutes' boiling; 
it can be dried rapidly at a low temperature and yet 
contain a significant amount of antiscorbutic substance 
after three months. 1 This property is present in the 
alcoholic extract of the juice, but not in the residue. 2 
According to Hess, 3 artificial orange juice will not act 
as an antiscorbutic. The same author found that orange 
juice may be filtered, boiled, rendered faintly alkaline 
and given intravenously, affecting a prompt cure of 
scurvy. Harden and Zilva 4 state that when orange juice 
is rendered slightly alkaline and allowed to stand several 
hours it retains only a trace of antiscorbutic. They con- 
clude that alkalies probably markedly reduce the anti- 
scorbutic property of food in a few hours. Lemon juice 
is about as effective as orange juice but not as readily 
taken by infants. Fresh limes have only one-fourth the 
power of fresh lemons, while preserved limes have no 
antiscorbutic power. 5 Grapes 6 have only about one- 
f .enth the antiscorbutic power of oranges, and bananas 
and apples also are poor in it. 3 Prunes have no value 
as antiscorbutic. 2 

Raw. fresh tomatoes are very efficient antiscorbutics 
and in contrast to some of the other vegetables can be 
dried rapidly or canned without losing much of this 
potency. Hess" found that one to four ounces daily of 
strained canned tomatoes will protect an infant from 
scurvy. Tomatoes are also rich in the water-soluble B 
and the fat-soluble A vitamine, according to Osborne 
and Mendel. 8 Thus, this vegetable contains all three 



1 Givens, M. H., and McClugage, H. B. : Am. Jour. Dis. of 
Children, 1919, 18, 30. 

2 Hess, A., and Unger, L. : Jour. Biol. Chem., 1918, 35, 479 — 487. 

3 Hess, A., and Unger, L. : Am. Jour. Dis. of Children, 1919, 
17, 221. 

4 Harden, A., and Zilva, S. S. : Lancet, 1918, 11, 320. 
5Chick, H.: Lancet, 1918, 11, 735. 

6 Chick, H., and Rhodes, M. : Lancet, 1918, 11, 774. 

7 Hess, A., and Unger, L. : Jour. Biol. Chem., 1919. 

s Osborne and Mendel : Jour. Biol. Chem., 1919. Ibid, 1920. 



SCURVY. 367 

vitamines. Canned tomatoes are a valuable antiscorbutic 
for institutional use, less practical in private practice. 

Potatoes are not especially rich in this element but 
because of the large quantity consumed by the popula- 
tion, these tubers afford a protection against scurvy, al- 
though much smaller quantities of the more potent 
orange juice would suffice. 

Specificity of Vitamines. Yeast, which contains the 
water-soluble B, which is a specific for beriberi, has 
practically no effect on scurvy or rickets, although it does 
stimulate growth. 1 By field 2 states that orange juice, 
when deprived of its water-soluble B, still prevents and 
cures scurvy, but does not stimulate growth, which it 
does, however, when water-soluble B is left intact, if 
large enough quantities are given (about 45 cubic centi- 
meters a day). Although orange juice prevents and 
cures scurvy, it has practically no effect on rickets. 3 Cod- 
liver oil, which contains the fat-soluble vitamine in large 
amounts, prevents and cures rickets in the presence of a 
sufficient quantity of the phosphorus ion, but has no 
effect on scurvy or beriberi. McCollum and Pitz 4 
showed that oats, when fed with fats and salts, were 
sufficient for proper growth and development in rats, 
and concluded that thus oats contained sufficient water- 
soluble vitamine. However, guinea pigs suffer from 
scurvy when fed only oats, which again shows that the 
absence of water-soluble vitamine is not responsible for 
scurvy. 

Pathological Anatomy. Two theories have received 
recognition regarding the underlying factors influencing 
the development of the pathological changes. 



i I less, A.: Am. Jour. Dis. of Children, 1917, 13, 98. 

- Byfield, A. 11., and Daniels, A.: Am. Jour. Dis. of Children 
1920, 19, 349. 

:; Mellanby, E. : Lancet, London, 1919, 1, 407. 

1 McCollum, E. V., Simmonds and Pitz, W. : Jour. Biol. Chem.. 
1917, 29. 



368 INFANT FEEDING. 

The first regards the changes in the bone marrow as 
the primary factor with resulting interference with the 
function of the hematopoietic system. 

The second suggests primary blood-vessel changes and 
classifies it essentially as a hemorrhagic disease, with- 
out important primary blood changes, and assumes that 
the same causative factors are responsible for the blood- 
vessel and bone marrow changes. 

The most prominent pathological manifestations are 




Fig. 23. — Scurvy showing lateral displacement of the 
metaphysis of both the upper and lower ends of the tibia and 
fibula. A similar displacement was present in practically all 
of the long bones. A subperiosteal hemorrhage is seen along 
the outer surface of the tibia which shows beginning cal- 
cification. In the process of healing in this infant that part 
of the metaphysis extending beyond the line of the shaft was 
completely absorbed in each instance and the bone took on a 
normal development in the direct line of the shaft. The 
"white line of Fraenkel" in this positive appears as a dark 
shadow, above this a rarified area is seen. 

found at the seat of most active bone growth, as at 
epiphyseal ends of the shafts of the long bones, the ends 
of the ribs and the skull, due to changes in all of the 



SCURVY. 369 

bone structures. A failure of the integrity of the epi- 
thelium of the blood-vessels is the underlying factor in 
the generalized hemorrhagic manifestations in the sub- 
periosteal tissues, the gums, skin and the hematuria. 

The gross pathological findings in a case of acute 
scurvy are characteristically typical, especially in the long 
bones. Grossly, there usually are large or small sub- 




Fig. 24. — Scurvy. Hemorrhage into both knee joints with 
displacement of left epiphyseal nucleus. Also showing white 
line. 

periosteal hemorrhages, most frequently found along the 
shafts and distal ends of the long bones of the lower 
extremities. The periosteum of the long bones is con- 
gested and swollen. Inflammatory changes rarely occur 
and there is no small round cell or leucocytic infiltration. 
Extensive hemorrhage may invade the soft tissue fol- 
lowing rupture of the periosteum. In old hemorrhages 
calcification of the elevated periosteum may be present 
21 



370 INFANT FEEDING. 

and fractures are not uncommon. Due to the rarefac- 
tion of the cortex, transverse fractures either single or 
multiple may be present, due* to muscle action, trauma, 
attempts at sitting, standing or falling. Lateral displace- 
ment of the metaphyses may result from trauma, tor- 
sion or hemorrhage. (Fig. 23.) Less frequently the 
epiphyses may be dislocated through intracapsular 
hemorrhage. (Fig. 24.) 

Changes similar to those seen at the ends of the long 
bones are noted at the anterior ends of the ribs with 
resulting beading. Subperiosteal hemorrhages are not 
uncommon over the skull and more especially in the or- 
bits resulting in exophthalmos. The latter may follow 
prolonged crying. The affection of the gums is due to 
the pressure exerted upon the mucous membrane by the 
teeth in dentition and also by external trauma as in bit- 
ing. The latter more commonly results in hemorrhages 
in the upper jaw. 

On sectioning the bone, the cortex is seen to be ex- 
ceedingly thin and brittle, the trabecular being thin and 
reduced in number. The marrow at the ends of the 
long bones is yellow and gelatinous instead of red. 

Microscopic changes, as seen in long bones, are most 
characteristically seen in the marrow. The bone marrow 
is poor in cellular elements, the connective tissue frame- 
work increases at the expense of the myeloid cells and 
blood-vessels. Hemorrhages are usually present in the 
marrow. 

The thin and fragile bone and poorly developed tra- 
becular are considered to be due to imperfect function- 
ing of the osteoblasts, which are reduced in number and 
appear smaller than normal. There is not an excess of 
osteoclasts, consequently normal resorption of bone oc- 
curs with diminished regeneration. 

The gross changes found in the heart in severe cases 
of scurvy usually consist in right-sided hypertrophy and 
fatty degeneration of the heart muscles. Occasionally 



SCURVY. 371 

an increased quantity of fluid is noted in the pericardial 
sac. There are no characteristic lesions of the valves 
secondary to scurvy. Jackson and Moore 1 found a 
marked thinning of the walls of the blood-vessels in their 
experimental animals and not infrequently thrombosis 
of the veins was noted. No constant lesions of the 
blood vessels in human scurvy have been described. In 
all probability hemorrhage occurs by diapedesis. Hess 2 
believes that a weakness of the vessel walls exists, as 




Fig. 25. — Scurvy. Showing fraying of the lower ends of 
the tibia and fibula. There is also a large hemorrhage about 
the tibia in this illustration whch casts a very hazy shadow. 
This hemorrhage is 24 hours old and followed trauma due 
to compression of the soft parts during the removal of blood 
from the heel for a Wassermann test. 

demonstrated by the "capillary resistance test," which 
consists in applying a tourniquet to the upper arm, thus 
subjecting the vessel walls to additional strain, generally 
causing the appearance of numerous petechias on the 
forearm. Following the trauma caused in taking blood 
from the heel for a Wassermann test, a massive hemor- 



1 Jackson. L. and Moore, J. J.: Jour. Infect. Dis., 1916, 19, 478. 
^ Hess. A. : Jour. A. M. A., 1921, 76, 694. 



372 INFANT FEEDING. 

rhage occurred into the soft tissues of the leg and foot 
in one of the author's cases. (Fig. 25.) 

Hess and Fish, 1 studying the blood in scurvy, found 
the coagulation time to be normal or only slightly in- 
creased. No deficiency of blood platelets or calcium or 
excess of antithrombin could be demonstrated. During 
the late war, scorbutic patients operated upon showed 
no particular tendency to hemorrhages. 

The respiratory tract usually shows no typical changes 
other than congestion and subserous hemorrhages. How- 
ever, in some of the fatal cases secondary pneumonia, 
infarcts and a generalized edema may be present. The 
alimentary tract beside the swollen gums, which are usu- 
ally the seat of more or less intense hemorrhage and not 
infrequently necrosis, shows no constant changes in the 
moderate types. In the severer forms hemorrhage may 
occur from any region of the stomach or the intestinal 
tract. The solitary follicles and Peyer's patches are 
usually infiltrated and may be ulcerated. The spleen is 
usually moderately enlarged and congested, as is also the 
liver. The latter may also be the seat of cloudy swell- 
ing and fatty degeneration ; similar changes are usually 
present in the kidneys. The most frequent changes in 
the nervous system are seen in the peripheral nerves, 
hemorrhage into the nerve sheath being the most com- 
mon. Hemorrhages are not uncommon in the brain sub- 
stances and pachymeningitis hemorrhagica interna have 
been described repeatedly. 

The lymph nodes draining areas of hemorrhage are 
enlarged. In guinea pigs McCarrison 2 noted frequent 
hemorrhages into the adrenals, greatly enlarging them, 
especially the medullary portion with degeneration of the 
cells in both cortex and medulla. The adrenalin content 
is much decreased. These findings have not been noted 
in human scurvy. 

i Hess, A., and Fish, M. : Amer. Jour. Dis. of Children, 1914, 8, 
386. 
2 McCarrison, R. : Oxford University Press, New York, 1921. 



,,? - 




Fig. 26. — Scurvy. Typical lesions of the gums, with hem- 
orrhage at the free edge of the gums of the incisor 
teeth. 



SCURVY. 373 

Symptoms. In the discussion of the symptoms of 
scurvy the acute and subacute types must be considered, 
and it must be remembered that the mild and severe 
forms of each of these will present varied clinical pic- 
tures. Due to the fact that the symptoms develop fol- 
lowing a prolonged use of an insufficient diet, a second- 
ary anemia, usually associated with more or less marked 
hemorrhages and bone changes, is found in infants show- 
ing other evidences of malnutrition. These may be the 
only clinical evidence of the disease in its mildest form. 
The typical acute case of severer type, after a more or 
less prolonged period of inanition, gives evidence of dis- 
comfort on being handled and shows a tendency to as- 
sume a flexed position of extremities. Tenderness on 
palpation of the limbs is noted and the infant shows a 
tendency to refrain from voluntary motion. These 
changes are most frequently noted in the lower extremi- 
ties. Palpable and visible swelling along the shafts may 
develop, although they are not constant findings. When 
present they are the result of the subperiosteal hemor- 
rhages. Less frequently these hemorrhages are noted 
in the epiphyseal regions but usually extend some dis- 
tance along the shaft of the bone which tends to dis- 
tinguish them from acute inflammatory joint conditions. 
Rare are the hemorrhages into the joints themselves, al- 
though they may occur. These may result in epiphyseal 
displacement. Among the rare lesions lateral displace- 
ment of the proliferating zones may exist. While swell- 
ing and discoloration of the gums is one of the most 
constant features, hemorrhage is not always visible. The 
typical lesions of the gums consist of a red or purple 
discoloration at the free edge of the gums of the incisor 
teeth. (Fig. 26.) This may exist on the posterior 
edge behind the teeth and not be present anteriorly. 
Hemorrhage in the peridental membrane, resulting in 
swollen and edematous gums, may be present before 
eruption of the teeth. Very rarely the gums may be 



374 INFANT FEEDING. 

markedly affected when there is no other obvious symp- 
tom of scurvy excepting malnutrition and secondary 
anemia. Not infrequently the incisor teeth become 
loosened and are lost. Palatal hemorrhage, most fre- 
quently seen over the middle part of the vault of the 
hard palate, should be looked for. Petechial and ecchy- 
motic hemorrhages may occur spontaneously in the skin 
but are more exceptional findings in the milder types 
unless secondary to trauma; more frequent are the or- 
bital hemorrhages resulting in a discoloration about the 
eye and hemorrhages into the conjunctiva. Occasionally 
a proptosis is noted. (Fig. 27.) Discoloration of the 
upper lid is more frequent than in the lower. Epistaxis 
occurs often. Edema is occasionally noted over the 
thickened part of the limbs and about the face. The 
visceral mucous membranes are commonly the seat of 
hemorrhage, resulting in hemorrhages from the gastro- 
intestinal tract and the genito-urinary tract. The appear- 
ance of blood in the vomitus and feces varies with its 
source and the time that it has been in contact with the 
digestive juices. The urine is usually diminished in 
volume, may contain albumin, casts, red and white blood 
cells in the presence of hemorrhage. An early appear- 
ance of blood stained urine is not uncommon. Pus cells 
may be present in considerable numbers after the sub- 
sidence of the hemorrhage. Pyrexia in infantile scurvy, 
although rather the exception than the rule, is by no 
means a rarity. The temperature may be raised to 101° 
or 102° F. when the infant comes under treatment, but 
it subsides generally within a few days as the acute 
symptoms of scurvy disappear. Hess describes the 
cardio-respiratory syndrome, consisting of increased 
pulse and heart beat often over 150, with respirations 
reaching 50 to 60. He believes that these phenomena 
may be associated with a disturbance of the vagus 
mechanism. Further changes in the nervous system may 
be present, due to hemorrhage or focal degeneration. 



SCURVY. 375 

The paresthesias due to peripheral nerve involvement 
have been described. Increased deep reflexes are usually 
present. The diagnosis of the subacute type is not al- 
ways possible by the clinical findings and may be de- 
pendent upon the reaction to antiscorbutic diets. The 
possibility of its existence should always be considered 
in the presence of an insufficient or improper diet and 
when infants are fed on heated milk, which is over long 
periods without the addition of antiscorbutics to their 



7 1 








J*- 





Fig. 27. — Scurvy. Bilateral proptosis, with discoloration 
about the eyes and hemorrhages into the conjunctivae. 

diet. Such infants usually show evidence of malnutri- 
tion and anemia, loss of appetite, increased tendon re- 
flexes, irritability and rapid pulse and respiration. In 
this class of cases, unless the diet is corrected, the typi- 
cal clinical picture may be precipitated at any time if 
the diagnosis is correct. 

Radiological Diagnosis. The diagnosis of the dis- 
ease in advanced cases may be made by the use of radio- 
grams. The density of the subepiphyseal region is ma- 
terially diminished where the lack of bone formation is 
especially marked. Just above this area, traversing the 
shaft in its transverse diameter, an irregular zone of 



3/6 INFANT FEEDING. 

increased density is seen in advanced cases of scurvy. 
This is seen as a lighter zone in the radiographic nega- 
tives and is described as the "white line of Fraenkel." 
This shadow can especially well be seen on the lower 
end of the femur and the distal ends of the bones of the 
forearm. This shadow receives its explanation from 
the anatomical finding in this portion of the diaphysis 
of an irregular chaos of calcified trabeculae, calcium and 
bony detritus, and also of bone marrow mixed with 
masses of blood and pigment. The structure of the 
spongiosa, which normally extends down to the place of 
transition of the shaft into the epiphysis, becomes sud- 
denly broken and is replaced by a tissue, thickened by 
compression, and showing no more an orderly structure 
of trabeculae, and this abnormal tissue shows a cor- 
responding shadow appearing always in the same posi- 
tion on the radiogram. From the above discussion it 
becomes clear that a certain degree of alterations in the 
bone is prerequisite for the appearance of a shadow in 
the radiogram. This is known as the "white line of 
Fraenkel." (See Figs. 24 and 25.) If this degree has not 
been reached, then the shadow is absent, even though 
the disease be present. A similar shadow is not infre- 
quently seen in severe cases of rickets. Less constant 
than this shadow are the subperiosteal shadows at the 
seat of hemorrhages. (See Figs. 23 and 25.) These 
shadows may be invisible, even at the height of hemor- 
rhage, becoming more and more distinct with age, due 
to the deposit of osteophytes. Fractures and infractions 
are demonstrable in scurvy. Other findings in scurvy 
are epiphyseal separation and displacements, hemor- 
rhages within the joint capsule and occasionally, but 
rarely, intramuscular hemorrhages may be demonstrated. 
Diagnosis. In the differential diagnosis of scurvy 
the possibility of its existence and its characteristic symp- 
toms must constantly be borne in mind. The presence 
of tenderness over the bones and tendency to fixation 



SCURVY. 377 

of the joints, the usual presence of multiple joint in- 
volvement, with evidence of hemorrhage in other parts 
of the body, in infants usually between 6 and 18 months 
of age and the history of improper diet or prolonged 
lactation, should lead to the suspicion of the presence 
of scurvy. 

Rachitis. When marked rickets is present the recog- 
nition of a superimposed scurvy is often difficult and a 
careful clinical study of the case may be necessary for 
its recognition, unless the complicating symptoms are 
pronounced. The dietetic test is the best means of dif- 
ferentiation in the moderate types. 

Rheumatic Fever. Pain, tenderness and swelling of 
the limbs in infants under 18 months should always lead 
to the suggestion of scurvy. In rheumatic fever the 
tenderness is usually associated with the joints and local- 
ized, while in scurvy there is almost invariably shaft 
involvement, even in the presence of joint involvement. 
The feeding history, presence of hemorrhages into the 
skin and from the mucous membranes will often com- 
plete the diagnosis. 

Syphilis. Syphilitic osteochondritis is usually asso- 
ciated with a history of early lesions — most commonly 
it occurs before the sixth month and shows the charac- 
teristic blood and spinal fluid findings in the infant and 
parents. The painful swellings are usually seen about 
the ends of the long bones and the radiological findings 
are characteristic. In later manifestations, in which 
periostitis ossificans is a very important finding, we see 
newly formed subperiosteal masses with bony structure. 
They are usually most marked in the middle of the di- 
aphysis of the tibia. Old cortex may often be differen- 
tiated from the newly formed subperiosteal bony masses. 
Cortical thickening is, therefore, an important point in 
differential diagnosis. 

Purpura. This disease is characterized by hemor- 
rhage, particularly into the skin. It is very rare in in- 



378 INFANT FEEDING. 

fants. It can usually be excluded by the tenderness of 
the shafts of the long bones in scurvy. The roentgeno- 
logical findings of scurvy will be absent. The intestinal 
and skin hemorrhages in the late stages of athrepsia may 
lead to some confusion unless a careful history is taken. 

Osteomyelitis. Scurvy is frequently mistaken for 
osteomyelitis by those who forget the possibility of the 
former. Osteomyelitis is usually confined to one limb, 
is characterized by a continued high febrile reaction, 
and by leucocytosis, and lacks the tendency to hemor- 
rhages in other parts of the body. The diagnosis can 
be settled by X-ray examination. 

Simple Fractures and Dislocations. These can usually 
be differentiated by the history of trauma, the singleness 
of the lesion and the absence of other typical clinical 
and radiographic lesions. 

Tuberculous Bone and Joint Lesions. The radio- 
graphic findings are usually sufficient for the differen- 
tiation of these two conditions. 

Bone Tumors. The malignant types are characterized 
by severe systemic reaction, the usual finding of a single 
bone lesion and the tendency to metastases in the visceral 
organs. 

Poliomyelitis. The pseudo-paralysis of scurvy may 
be mistaken for this condition. In the differentiation 
the history of an acute febrile onset in an infant previ- 
ously in good health and the tendency to general tender- 
ness of extremities, rather than localized, must be con- 
sidered. The further progress of the case will usually 
complete the diagnosis. 

Acute Nephritis. In the presence of edema and the 
urine containing albumin, casts and blood, the differen- 
tiation may be very difficult and it is not to be forgotten 
that acute nephritis may be present as a complication of 
scurvy. The course of the disease and the reaction to 
dietetic treatment may be the only means of differentia- 
tion, as to the importance of the urinary findings. 



SCURVY. 379 

Pleuritic and Peritonitic Pain. A careful study of' 
the chest and abdominal viscera for evidence of acute 
inflammatory conditions are necessary to eliminate the 
possibility of a confusion in the diagnosis between in- 
flammatory changes in these parts. 

All other conditions associated with bone and blood 
changes, and in the latter leading to hemorrhage, may 
at times require differentiation. 

Prognosis. There are few diseases in which the 
effect of treatment is so striking as in mild infantile 
scurvy; under efficient antiscorbutic diet the tenderness 
and pain on movement are usually appreciably less in 
forty-eight hours; although such rapid diminution of 
the tenderness and pain may be expected; other symp- 
toms persist longer; the subperiosteal hemorrhages, if 
large, may cause some deep thickening to remain for 
two or three weeks. Occasionally the thickening re- 
mains for many weeks or months, in spite of the com- 
plete disappearance of all other symptoms of scurvy. It 
should be remembered that an individual tendency to 
scurvy may exist and that further indiscretions in diet 
may readily lead to recurrences. In severe cases the 
prognosis must be guarded because of the liability to 
severe hemorrhages, syncope from the profound ane- 
mia, and death from diarrhea, broncho-pneumonia or 
exhaustion. 

Treatment. Prophylaxis. In discussing the etiology, 
certain facts were mentioned, which it is of importance 
to bear in mind in a consideration of the prophylactic 
treatment of scurvy, namely : that this disease is the 
result of the deficiency or absence of a certain substance 
in the diet, which in all probability belongs to the so- 
called group of vitamines. Human milk usually con- 
tains a sufficient amount of this antiscorbutic to protect 
the infant, fresh, raw cow's milk, although relatively low 
in it, contains enough for the normal development of 
the infant if given in sufficient quantities, although its 



380 INFANT FEEDING. 

content varies with the diet of the cow. This anti- 
scorbutic is reduced or destroyed by the ageing of milk; 
heating the milk has the same influence. Proprietary 
foods and cereals are especially prone to be deficient 
foods because of the process of heating in their prepara- 
tion and the low vitamine content of the cereals. Many 
fruit juices and certain vegetables, especially if fresh, 
are rich in antiscorbutic. With this knowledge at hand, 
scurvy can nearly always be prevented by proper atten- 
tion to the antiscorbutic value of the diet in infant feed- 
ing. If the diet is low in antiscorbutic, it should be sup- 
plemented by sufficient quantities of foods known to be 
rich in this substance. 

If babies are breast-fed, they rarely develop scorbutus, 
so that breast feeding is one of the best preventive 
measures. To avoid the danger of the vitamine content 
of the milk becoming too low, the lactating mother 
should partake of a liberal amount of cow's milk, leafy 
vegetables and fruits. Moreover, when the mother's 
milk is scanty and so quantitatively poor in antiscorbutic, 
sufficient cow's milk, vegetables and orange juice should 
be added to the infant's diet to fulfill the baby's vita- 
mine requirements. In the artificially fed, sufficient 
quantities of fresh, raw cow's milk will usually prevent 
scurvy, but the great danger of bacterial infection from 
contaminated raw milk usually more than counter- 
balances the danger of this disease. Consequently, un- 
less certified milk can be obtained, it is better to boil 
tbe milk, even if previously commercially pasteurized, 
and during the very hot weather we even advise boiling 
certified milk. If, however, fresh raw milk is used, too 
dilute a modification should not be given, as here again 
the quantitative amount of antiscorbutic may be insuf- 
ficient. This milk should be obtained, if possible, from 
cows properly fed on plenty of greens. During the 
winter, when the diet of the cattle is mostly grains, even 
the very young infants should be given orange juice. 



SCURVY. 381 

The number of babies feci on heated milk, either pas- 
teurized or boiled, is continually increasing. An anti- 
scorbutic, such as orange juice, lemon juice, tomatoes, 
etc., should in every instance be given to these infants. 
We start as early as the sixth week with five drops 
diluted with water, twice daily, and gradually increased 
until two to four drams are given daily by the third 
month and about one ounce by the fifth or sixth month, 
so as to prevent the vitamine deficiency for even a short 
period and thereby avoid the danger of latent scurvy. 
If the babies object to it, it may be diluted with water 
and a little cane sugar added. If it is regurgitated, a 
small amount of alkali may be added just before feed- 
ing and then it is usually better tolerated. Orange juice 
is continued throughout early childhood. Strained, 
warmed (not cooked) tomatoes, either raw or canned, 
may be used instead of orange juice, in doses of one 
dram to one ounce daily. (The latter may be given to 
infants over three months of age.) These are as well 
borne as orange juice, even by very young infants. Later 
on, potatoes cooked with their jackets on serve as effici- 
ent antiscorbutics, as do also the leafy vegetables. As 
cooked vegetables have lost considerable of their anti- 
scorbutic potency, the amount fed must be sufficient to 
protect against scurvy. One tablespoonful a day is usu- 
ally adequate. The vegetables should be as fresh and 
young as possible. 

Proprietary and other foods subjected to prolonged 
heating should be avoided as much as possible 
and if given must be supplemented by sufficient quan- 
tities of antiscorbutics. 

The basis of all infants' diets should be fresh, clean 
milk. 

Active Therapy. When scurvy develops, the active 
treatment is mainly dietetic, no medicinal agent influenc- 
ing the underlying condition. Orange juice must be 
given at once, starting with small doses of a few drams 



382 INFANT FEEDING. 

daily and rapidly increasing within two days or so to 
one or two ounces. This may all be given at one time, 
an hour before the mid-morning feeding, or divided into 
two or three doses. Exceptionally, in extremely severe 
cases, when orange juice cannot be given by mouth, it 
may be boiled, filtered and rendered faintly alkaline, and 
administered intravenously. Lemon juice is just as ef- 
ficient but less palatable. Orange juice will cure scurvy, 
even if the causative food is continued, because the fruit 
juice supplies the lacking element in the diet. It is bet- 
ter to change the food, however, unless there is some 
special indication for continuing it. Fresh milk, even 
if boiled, should be added in sufficient quantities if the 
diet contains too little milk. Fresh green vegetables or 
vegetable soup may be added to the diet if the child is 
old enough to digest them. A tablespoonful daily of 
boiled, mashed potato is a good antiscorbutic. Other 
vegetables, as tomatoes, carrots, celery, turnips, and 
green leaves, are good antiscorbutics but their efficacy 
is much below orange juice. They should be fed when 
the infant's age permits. (See additional foods, page 161. ) 

Even in the acute florid type of scurvy, recovery is 
rapid and complete under the above treatment. Ten- 
derness of the extremities disappears in a few days and 
the hematuria usually ceases within a week. The swell- 
ing lasts much longer. The dietetic treatment should 
be continued for a period of months so that bones and 
tissues may be fully restored to normal. 

Actively scorbutic infants should be moved and han- 
dled as little as possible for the first few days under 
treatment. Sedatives may be necessary for the first day 
or so to control the pain. If fractures or epiphyseal 
dislocations occur, splints are necessary for immobiliza- 
tion. In cases of marked anemia and severe hemor- 
rhages, a blood transfusion may help. During con- 
valescence, iron preparations should be given. 



SCURVY. 383 

Rachitis, if present, should be recognized and treated 
simultaneously. 

Good hygienic surroundings should be provided to aid 
in convalescence. 



PART VIII. 
Acidosis. 



By the term acidosis we refer to that condition in 
which there is a diminution in the reserve supply of 
fixed bases in the body fluids and tissues. The physio- 
chemical reaction of the blood remains unchanged ex- 
cept in extreme conditions. 

Acidosis may result from any one of the following 
factors or a combination of them : 

(1) An insufficient intake of food and fluid, with re- 
sulting dehydration, or excessive production of 
acetone bodies, or both. (Anorexia, starvation, 
vomiting and diarrhea.) 

(2) Incomplete oxidation of the organic acid radicals. 
(Diabetes, cyclic vomiting, infections, anhydremia, 
and conditions resulting in insufficient aeration of 
the blood as cardiac and pulmonary disease, suffo- 
cation, excessive exercise, etc.) 

3) Defective neutralization of acid in the body by am- 
monia. ( Nephritis. ) This is due to the fact that 
the acid phosphates causing the acidosis fail to call 
forth ammonia production rather than the failure 
of ammonia production per sc. 
(4) Inadequate elimination : 

a. Of carbon dioxide by the lungs. (Pulmonary 

disease.) 

b. Of acid by the kidneys. (As acid phosphates 

in nephritis and anhydremia.) 
A sharp distinction must be drawn between aceto- 
nuria and acidosis. This is necessary because of the 
wide-spread confusion which has arisen, in the interpre- 
tation of the relationship which acetonuria bears to acid- 
(384) 



ACIDOSIS. 385 

osis. Acetonuria consists merely in the presence of 
acetone-bodies in the urine, and may or may not be 
accompanied by symptoms of acidosis. Acetone body 
acidosis should be applied to that condition in which an 
excess of these bodies are present in sufficient quantity 
to neutralize enough of the bases to appreciably diminish 
the alkali reserve. Acidosis may, however, be due to 
an excess of other acid-bodies, such as acid phosphates, 
lactic acid and carbonic acid. 

Mechanism of Acid-base Equilibrium. As the blood 
plasma has approximately the same composition as the 
tissue juices and the relative alkalinity of the tissues has 
a fairly constant relation to the alkalinity of the plasma, 
it is sufficient to study the regulation of the acid-base 
equilibrium in the blood. Acids are constantly being 
produced in the course of metabolism. Protection is 
afforded the body against these in fundamentally the 
same manner in health and disease. In the latter the 
body responds within its reserve capacity by a quanti- 
tative increase in its normal processes of oxidation, ex- 
cretion and neutralization. 

The blood is normally slightly alkaline. Nevertheless, 
by virtue of its carbonates, phosphates and proteins, it 
can neutralize a moderate amount of acid. This ability 
to neutralize acid or base is termed "titratable value" 
in distinction from the actual reaction. The true or ac- 
tual reaction of a fluid concerns itself only with that 
portion of acid or base which, after going into solution, 
becomes dissociated into hydrogen and hydroxyl ions. 
The titration value of a solution is a broader term, since 
it includes not only the free hydrogen and hydroxyl ions 
present, but all the reserve of undissolved and undis- 
sociated hydrogen or hydroxyl, which can be liberated 
as ions. — Sellards. 1 Henderson 2 has pointed out and 

1 Sellards, A. W. : Princ. of Infant Feeding, Harvard U. Press, 
1917. 

- I [enderson, L. J. : Amer. Jour, of Physiology, Vol. 21, 1908, 
p. 427. 



386 INFANT FEEDING. 

established that the mono- and di- sodium phosphates and 
carbonates of the blood constitute one of the funda- 
mental features in the regulation of neutrality, since the 
monosodium salt (NaH 2 P0 4 ) is acid and the disodium 
salt (Na 2 HP0 4 ) is alkaline. The normal carbonate and 
bicarbonate of the serum act in a similar manner and are 
present in much larger quantities and therefore of even 
greater importance. This mixture of phosphates and car- 
bonates is the most effective in maintaining a constant re- 
action ; it is extremely efficient not only in aqueous solu- 
tion but in the presence of proteins, such as serum affords, 
and these moderately enhance its value. This action is 
practically limited to the hemoglobin, the other blood pro- 
teins having very little action in retaining the constant re- 
action of the blood, on account of the fact that they are 
inefficient in the particular reaction of the blood although 
on other reactions they have a marked effect. 1 Free car- 
bonic acid is present in the body fluids in such concentra- 
tion that it automatically converts into bicarbonate all 
bases not bound by other acids. The bicarbonate, there- 
fore, under the conditions existing represents the excess 
of base which is left after all the non-volatile acids have 
been neutralized and is available for the immediate neu- 
tralization of further acids. In this sense it constitutes the 
alkaline reserve of the body. — Van Slyke. 2 The bicar- 
bonate concentration of the blood is representative of that 
of the body fluids in general, and is normally maintained 
at a definite level, which forms approximately a 0.3 per 
cent, solution in the blood plasma. Entrance of free acids 
reduces it to an extent proportional to the amount of 
the invading acid. Sodium bicarbonate is the chief sub- 
stance concerned with this mechanism. 3 The proteins 
and phosphates in the blood play a lesser role. An acid 
or even a neutral reaction of the blood is incompatible 



i Henderson, Y. : Jour. Biol. Chem., 1920. 

2 Van Slyke, D. D. : Jour. Biol. Chem., 1917, Vol. 30, p. 289. 

3 Howland and Marriott : Penna. Med. Jour., Vol. 21, 1918, p. 
429. 



ACIDOSIS. 387 

with life, so that the phrase "increased acidity" really 
means reduced alkalinity. 

Carbonic, phosphoric, sulphuric and among the organic 
lactic acids are normally formed as end products in the 
metabolic processes. These acid substances must be neu- 
tralized and excreted without disturbing the normal de- 
gree of alkalinity of the tissues if the organism is to 
remain in a state of health. When there is an inability 
on the part of the body to maintain its alkali reserve, 
acidosis results. 

The defenses of the body against acidosis are princi- 
pally pulmonary ventilation, excretion of acids by the 
renal tissues and neutralization of acids by ammonia. 

Pulmonary Ventilation. In the blood carbonic acid 
in part unites with the alkalies in the blood to form bi- 
carbonate and some remains in the solution in the plasma. 
The venous blood thus loaded with carbonic acid is car- 
ried to the capillaries of the lung tissue. Here carbon 
dioxide diffuses through the thin capillary and alveolar 
walls into the alveolar air because the pressure of C0 2 
is less in the inspired air than in the blood. Thus, car- 
bon dioxide is given off by the lungs without the loss 
of alkalies from the body and the blood becomes more 
alkaline again. If an excess of carbonic acid accumu- 
lates in the blood, even a very small increase of the 
H ion concentration stimulates the respiratory center, 
with a resulting increased rapidity and depth of respira- 
tion and increased CO2 excretion. Sellards has a some- 
what different explanation for this hyperpnea. He main- 
tains that as the fixed bases become depleted the oxygen 
is still carried by the arterial blood but the resulting 
carbon dioxide gradually accumulates in the tissues, 
since there is not an adequate supply of bases for trans- 
porting it to the lungs. With this accumulation of car- 
bon dioxide, the tissues are no longer able to utilize the 
oxygen brought to them ; the individual becomes dys- 
pneic and suffers from subjective symptoms of suffo- 



388 INFANT FEEDING. 

cation just as though he were deprived of air. The 
oxygen, since it cannot be taken up by the tissues, re- 
mains in the venous blood, giving it an arterial color. 

Howland and Marriott 1 state: If, on the other hand, 
an acid, such as beta-oxybutyric or lactic, is poured into 
the plasma, as it passes through the tissues, a certain 
amount of the bicarbonate is neutralized and carbon di- 
oxide is set free in solution. The excess of carbon di- 
oxide is removed as before and the blood reaction returns 
to normal. Some bicarbonate has, however, been neu- 
tralized so that the plasma has become a weaker solution 
of bicarbonate. When this solution takes up carbon 
dioxide from the tissues its reaction becomes more acid 
with the same amount of dissolved carbon dioxide as 
formerly. Roughly speaking, if the bicarbonate of the 
plasma is reduced one-half, only half as much carbonic 
acid can be carried in solution as formerly, if the re- 
action is to remain the same as before. By doubling 
the ventilation in the pulmonary alveoli the dissolved 
carbonic acid of the plasma may be diminished about 
one-half; at the same time the concentration or tension 
of carbon dioxide in the pulmonary alveoli is also dimin- 
ished one-half. The carbon dioxide tension in the al- 
veolar air, for this reason, is a measure of the extent 
to which the bicarbonate reserve of the plasma is de- 
pleted, and increased pulmonary ventilation is one of the 
symptoms of acidosis. 

Increased pulmonary ventilation serves to prevent a 
significant change in the reaction of the blood, but it 
cannot prevent a depletion of the bicarbonate reserve 
of the plasma. This reserve eventually would be en- 
tirely exhausted were it not for other means of defense 
and for the provision for a replenishment of the alkali 
reserve. 

Excretion of Acid by Renal Tissues. An acid urine 
is excreted normally by the kidneys from an alkaline 



1 Howland and Marriott : Ibid. 



ACIDOSIS. 389 

blood, thus sparing alkalies to neutralize more acids of 
metabolism. A small amount of free acid is present in 
the urine. Most of the acid in the urine, however, is 
excreted as acid phosphate which is formed from the 
alkali phosphate of the blood plasma, by the follow- 
ing reaction : Na 2 HP0 4 plus HoO plus C0 2 , equals 
NaH 2 P0 4 (excreted in urine) plus HNaC0 3 (remains 
in the blood). The base thus spared serves to replenish 
the bicarbonate reserve. Some alkaline phosphate is, 
however, excreted in the urine, and although no alkali 
is lost through the lungs, some is lost in the urine by the 
excretion of the salts of phosphoric, sulphuric, lactic acid, 
etc. To compensate for this alkali loss there is usually 
a sufficient quantity of alkalies taken with the food. 

Neutralization of Acids by Ammonia. Ammonia 
formed instead of neutral urea, neutralizes acids in the 
plasma and is excreted in the urine as ammonium salts. 
Ammonia occurs in the urine physiologically only to the 
extent which is needed for the neutralization of acids, 
the remainder of the ammonia being promptly converted 
into urea. When there is an increased accumulation of 
acids in the blood, more ammonia is formed to neutral- 
ize them and is an important safety factor in maintaining 
the alkali reserve. The presence of an increased amount 
of ammonia in the urine does not, in itself, indicate an 
acidosis but rather that the body is reacting to prevent 
acidosis. 

Clinical Types. As previously stated, it is necessary 
to draw a distinct line between acetonuria and acidosis. 
Most of the studies of the past have dealt mainly with 
the acetone body acidosis. However, in the light of 
more recent experimental and clinical investigations the 
prominence of other acid bodies such as the acid phos- 
phates, carbonic and lactic acid have assumed a more 
prominent position as causative factors, either as distinct 
or mixed types of acidosis. 



390 INFANT FEEDING. 

Acetone Body Acidosis. Acidosis in the course of 
diabetes is a recognized representative of this type. The 
development of hyperpnea and drowsiness, in the course 
of diabetes, indicates clinically that such an acidosis ex- 
ists. A study of the C0 2 tension in the alveolar air 
and the bicarbonate reserve of the plasma should always 
be made with the first clinical or laboratory evidence of 
a beginning acidosis. As a prophylactic measure such 
tests should be made at regular intervals during the 
course of the disease. Fortunately, diabetes is a rare 
disease in children, but a very fatal one. Acidosis of 
this type occurs in the presence of ileo-colitis (bacillary 
dysentery ) , also at times at the onset of measles, scarlet 
fever, and in the presence of respiratory infections. 
Other conditions, such as recurrent vomiting, acute in- 
fections and nutritional disturbances which are com- 
monly associated with acetone body acidosis will be 
treated individually because of their clinical importance. 

Acidosis in the Course of Acute Infectious Diseases. 
Acute toxic conditions out of proportion to the seeming 
severity of the infection are frequently seen in the course 
of acute infectious diseases in young children. They 
are frequently due to the production of sufficient amounts 
of acid bodies to cause a definite acidosis. This increase 
in acid body production must be viewed in the light of 
an expression of the toxemia and not as the cause of the 
condition. The clinical picture may, however, be greatly 
influenced by the production of these substances. 

Acute Upper Respiratory Tract Infection Associated 
with Acidosis. For several years past we have been 
experiencing epidemics of acute upper respiratory infec- 
tion associated with evident inflammation of the tonsils, 
pharynx, naso-pharynx and nasal mucous membranes 
resulting in an injection and glazed appearance of the 
mucous membranes. It is frequently unaccompanied by 
follicular involvement of the tonsils. Nausea and vomit- 
ing are early manifestations and may disappear in one 



ACIDOSIS. 391 

or two days or in fatal cases persist throughout the 
course of the disease. Usually by the second day after 
the beginning of vomiting an acetone odor is noted in 
the breath. Many of the cases early show acetone 
and a considerable number diacetic acid in the urine. 
Not infrequently, however, the mild cases run their 
course without these latter findings. Diarrhea is pres- 
ent in some of the cases and may be accompanied by 
marked evidence of intestinal fermentation. The ma- 
jority of our cases, however, were associated with a 
flat abdomen and constipation. In the severe cases hy- 
perpnea develops and may be the most marked of all 
of the symptoms. The children develop anhydremia, 
features are drawn, eyes sunken, skin becomes dry and 
loses its turgor, they become apathetic and later stupor- 
ous, and unless relieved develop profound coma. The 
epidemics were usually seen during the winter and 
spring months, and more commonly affect children be- 
tween the ages of 1 and 6 years. Younger infants, how- 
ever, may develop this condition and it is not infrequently 
seen in the breast-fed. Physical examination in the 
absence of tympany usually reveals more or less rigidity 
of the abdominal muscles and an enlarged liver. In 
some of the severe types icterus may develop. Throat 
cultures, taken early in the course of the disease, have 
in most instances in my cases shown a short chain small 
streptococcus. 

What relationship the acute infection in the pharynx 
bears to the clinical picture is undecided. In all prob- 
ability it is due to a general toxemia. However, the 
possibility of an acute gastritis, with secondary starva- 
tion, due to the inability to retain food, must not be over- 
looked as the possible cause of the acidosis. 

A number of our cases were seen in children who 
had previously had a radical tonsil operation performed, 
so that they could not be related to pus infections of 



392 INFANT FEEDING. 

the tonsils themselves. Rachford, 1 who has described 
these cases under the title of "Epidemic Acid Intoxi- 
cation," has seen a large number of fatal cases. This 
has not been our experience in the Chicago epidemics, 
most of the cases running a comparatively short course 
of from two to six days, ending in a rapid convalescence. 

Pulmonary and Cardiac Diseases. In the pneumonias, 
empyema and bronchial asthma and other types of mas- 
sive involvement of the pulmonary tissues, and in car- 
diac diseases associated with decompensation, carbon di- 
oxide frequently accumulates in the blood in amounts 
in excess of the normal, resulting in a carbon dioxide 
acidosis. This leads to increased stimulation of the res- 
piratory center, with resulting hyperpnea. The carbon 
dioxide tension in the alveolar air is diminished but on 
account of the peculiar character of the acid causing the 
acidosis there is no diminution in the alkali reserve. ' In 
some cases Howland and Marriott found that lactic acid 
was produced as a result of the partial asphyxia and 
in these cases a slight diminution in the alkali reserve 
was noted. 

Chronic Upper Respiratory Infections. Sedgwick- 
directs attention to the surprising results obtained fol- 
lowing removal of the tonsils and adenoids in some of 
his cases of recurrent or periodical vomiting. He found 
that not infrequently tonsillitis or rhino-pharyngitis pre- 
ceded the attacks. The possibility of focal infection 
should therefore be borne in mind in the recurrent types 
of vomiting associated with acidosis. The type of re-' 
current vomiting, probably a toxic neurosis which re- 
sembles migraine of later life in many of its clinical and 
laboratory findings and familial tendencies, should be 
given due consideration in an analysis of this group. 

Acidosis Associated With Diarrheal Conditions. It 
has been shown by Howland and Marriott, 3 and the 

1 Rachford, B. K. : Arch. Ped. vol. 37, Nov., 1920, p. 651. 

2 Sedgwick, J. : Jour. Dis. of Children, iii, 1912, 209. 

3 Howland and Marriott : Penna. Med. Jour., April, 1918. 



ACIDOSIS. 393 

work has been confirmed by Yllpo 1 and Schloss, 2 that, 
in the diarrhea of infants accompanied by profuse watery 
stools (intoxication, cholera infantum, anhydremia, etc.), 
a severe acidosis may result. It is not present in all 
cases of diarrhea but may be a very serious and often 
a fatal complication. The carbon dioxide tension of 
alveolar air is low ; frequently it sinks to 20 mm. or 
less, the alkali tolerance is much increased, the alkali 
reserve is greatly diminished and the hemoglobin dis- 
sociation curve is altered. Children suffering from this 
form of acidosis show, in addition to the other symp- 
toms referable to diarrhea and anhydremia, hyperpnea 
and psychic changes. 

The cause of this acidosis is not always evident, al- 
though it is in all probability frequently influenced by 
an insufficient intake of food, starvation due to vomiting, 
anhydremia through loss of fluids by vomiting and diar- 
rhea, and excessive loss of bases through the intestines 
and disturbances in carbohydrate metabolism may all be 
factors. Although the acetone bodies are at times in- 
creased, they may be within normal limits. In a con- 
siderable number of cases the inorganic phosphorus of 
the serum is increased. The anhydremia results in a 
diminished blood volume, with a secondary diminished 
blood flow especially in the capillaries, which leads to a 
partial tissue asphyxia and increased lactic acid produc- 
tion. — Marriott. 

From our present knowledge we are led to believe 
that increased production and an insufficient elimination 
of acids is, therefore, largely responsible for the develop- 
ment of acidosis in the course of the diarrheal conditions. 

Acidosis Secondary to Starvation. It is a well-known 
fact that in partial starvation acetonuria is a frequent 
finding. The same is true when patients suffering from 
infections are underfed. The presence of acetone in 



i Yllpo : Ztschr. f. Kindcrh., Vol. xiv. 1916. 

2 Schloss, O. : Amcr. Jour. Dis. of Children, Vol. 13, 1917, o. 218. 



394 INFANT FEEDING. 

these cases does not signify that they must necessarily 
be in a state of acidosis. 

The work of Yllpo, 1 in 1914, was a stimulus to the 
study of this subject in new-borns. He claims to have 
found that the human organism at birth, is in a state 
of "physiologic acidosis;" as evidenced by chemical ex- 
amination of the blood. Sehan 2 studied ten new-borns, 
from 1 hour to 8 days of age, and found that during the 
first few days, when the baby received practically no food 
at all, there was no definite decrease in C0 2 tension, 
which is indicative of acidosis such as Yllpo claims to 
have found. His results with the alkali tolerance tests 
in the normal new-borns led him to believe that they 
were not suffering from acidosis. He also found that 
acetone is practically absent from the urine of a nor- 
mal new-born. 

Veeder, 3 as a part of a general study of acetone body 
acidosis in childhood, made a number of experiments to 
obtain figures of the degree of acetonuria resulting from 
inanition. He believes that there is but little increased 
output of acetone bodies during a period of twenty-four 
hours inanition in a healthy child. In the cases in which 
inanition was terminated at the end of twenty-four hours, 
there was a continued increased elimination of acetone 
on the following day, which in some instances was greater 
than the amount eliminated on the day of the inanition. 
This fell rapidly, so that by the second day normal figures 
were again obtained. 

In the remaining cases the inanition period was con- 
tinued for a second twenty-four hours before the child 
was placed on the original diet. A rapid increase in 
acetone elimination took place during the second twenty- 
four hours. 



1 Yllpo, A. : Neugeborenen-Hunger und Intoxikationsacidosis, J. 
Springer, Berlin, 1916. 

2 Sehan, M. : Am. Jour. Dis. of Children, Vol. 18, 1919, p. 42. 

3 Veeder, B. ; Johnson, M. R. : Am. Jour. Dis. of Children, V. 
13, 1917, p. 89. 






ACIDOSIS. 395 

Veeder does not believe that there is a relationship 
between the degree of acetonuria and the state of the 
child's nutrition, thin children giving the same results 
as fat ones. He found that the amount of beta-hydroxy- 
butyric acid (in terms of acetone) eliminated was as a 
rule from two to four times as much as the quantity of 
combined acetone and diacetic acid. 

The nitrogen and ammonia of the urine was deter- 
mined daily. There was at most a very slight actual 
increase, or percentage increase, in the ammonia elimina- 
tion on the first day of inanition, however, later a marked 
increase took place. 

Gamble and his co-workers, 1 using as subjects epileptic 
children who were being fasted as a therapeutic measure, 
undertook to determine the extent to which the reduction 
of the plasma bicarbonate during fasting is due (1) to 
depletion of the inorganic base of the plasma, and (2) 
to the concentration of ketone acids developing in the 
plasma. It was found that the total inorganic base con- 
centration was during fasting accurately sustained at its 
usual average value. The reduction of bicarbonate was 
thus apparently due entirely to the concentration of ab- 
normal organic acids in the plasma. This inference was 
sustained by direct measurements of the concentration of 
ketone acids in the plasma. It was also found that small 
amounts of sucrose by mouth brought about a restoration 
of the bicarbonate concentration to its usual size. From 
these data it is inferred that glucose rather than bicar- 
bonate is the logical agent in the treatment in non-diabetic 
ketosis. 

Abt 2 has described a series of cases of acid intoxi- 
cation recurring in infants previously healthy, at about 
the weaning period. In one family two children had 
previously died from this affection, the case described 



1 Gamble, J. L., Ross, S. G., and Tisdall, F. F. : Transactions 
Amcr. Pcd. Society, 1922. 

2 Abt : Amcr. J. Med. Sc, 147, 1914, 86. 



396 INFANT FEEDING. 

being the third infant born to this family. W. F. Orr 
had reported a series of five children in the same family 
who died with symptoms similar to those described by 
Abt. The illness usually occurs in large, robust, previ- 
ously healthy infants — in some cases the infants had 
shown a stationary weight curve before the onset. As 
in some of his cases I have seen three cases occurring 
in infants who suddenly weaned themselves because of 
dissatisfaction with the food from the breast, following 
which they also declined to take sufficient artificial food. 
As several of our cases have occurred before the close 
of the period of lactation the question arises as to 
whether the insufficient breast milk supply may not have 
led to partial inanition which became acute with spon- 
taneous refusal of artificial food, resulting in complete 
starvation. The possibility of infection as a precipitat- 
ing factor must, however, not be overlooked. 

Post-Operative Acidosis. Morriss 1 found that the 
capacity of the plasma for combining with the carbon 
dioxide is decreased after ether and chloroform anes- 
thesia ; in other words, one influence of the anesthetic 
is toward depletion of the alkali reserve. 

Jeans- found that the acetone bodies of the blood 
were somewhat increased after operation in about two- 
thirds of the children studied, the maximum amount be- 
ing found in most instances about twenty-four hours after 
operation. The plasma carbonate was reduced in about 
two-thirds of the cases, the greatest reduction occurring 
in most instances about twenty-four hours after opera- 
tion. When more closely compared there was found to 
be no close relation between the increase of acetone 
bodies and the reduction of plasma carbonate. In most 
instances, especially in those cases in which the plasma 
carbonate was much reduced, the acetone bodies were 
entirely inadequate to account for the degree of reduc- 



i Morriss : Jour. A. M. A., May 12, 1917. 

2 Jeans: Papers of the St. Louis Clinic, 1917. 



ACIDOSIS. 397 

tion of plasma carbonate. The undetermined acid fac- 
tor was apparently of much greater importance than the 
acetone bodies in the reduction of reserve alkali. The 
starvation incident to operation seems to play no part 
in the production of this undetermined factor. 

Acidosis of Renal Origin. The ability of the kidneys 
to excrete acid, especially acid phosphate, is one of the 
chief defensive mechanisms of the body. Failure of 
this mechanism even without increased production of 
acids, results in acidosis. Occasionally in nephritis acid- 
osis occurs and Howland and Marriott 1 have shown that 
when acidosis is present there is an accumulation of un- 
excreted phosphate in the blood plasma. There is no evi- 
dence that any abnormal acid is produced. In these cases 
of acidosis where hyperpnea is present, the C0 2 tension in 
the alveolar air is lower than normal, the alkali reserve 
of the blood is depleted, and there is an increased "al- 
kali tolerance." No acetone bodies are to be detected 
in the urine and the ammonia excretion is normal or 
diminished. Failure to produce ammonia to neutralize 
the retained acid is an additional factor in the produc- 
tion of the acidosis of nephritis, and represents a weak- 
ening of another of the body's defenses. 

Acidosis Secondary to Bums. Acidosis frequently 
develops following severe burns. Marriott has found 
this to be a mixed type and is due in part to acetone 
bodies and in part to lactic acid. 

Symptoms. The onset is usually relatively insidious. 
An early and the most important sign is hyperpnea, char- 
acterized by deep, pauseless respirations. The rate is 
usually moderately increased as compared to the great 
increase in depth. It is both thoracic and abdominal, 
the great amplitude of the respiratory excursion causing 
considerable effort and often the accessory respiratory 
muscles are brought into action. This type of breathing 



1 Howland and Marriott : Arch. Int. Med., Vol. xviii, 1916, 
p. 708. 



398 INFANT FEEDING. 

is described as "air hunger" and is the manifestation of 
an effort to increase pulmonary ventilation. Eventually, 
in fatal cases, there is exhaustion of the respiratory cen- 
ter, the respirations become feebler with occasional deep 
gasps and finally cease. Because of the increased aera- 
tion of the blood, the lips and cheeks are often a bright, 
cherry red. 

The sensorium is markedly affected. At first, there 
is extreme restlessness and excitement, later apathy, 
drowsiness and stupor develops. Anhydremia frequently 
develops, manifested by sunken eyes, depressed fontanel 
and dry skin hanging in folds, more especially in the 
presence of repeated vomiting. The face is anxious and 
pinched. Diarrhea may accompany the acidosis. A 
"'fruity" odor of the breath is sometimes present — this 
is characteristic of acetone body acidosis only. Dex- 
trose alone, or in combination with lactose and galactose, 
may appear in the urine, 1 in the particular form of acid- 
osis occurring in anhydremia. The degree of leucocy- 
tosis and fever depends upon the accompanying disease. 
Ilvperpnea without cyanosis is the only reliable and 
pathognomonic clinical symptom. The various laboratory 
tests show an impending acidosis before any symptoms 
are manifest. The laboratory tests confirm the diag- 
nosis. They give positive evidence of the presence or 
absence of acidosis, even in absence of characteristic 
symptoms. 

The determination of the carbon dioxide tension in 
the alveolar air is a relatively simple, bedside procedure, 
if the colorimetric method of Marriott- is used. In 
infancy the normal carbon dioxide alveolar air tension 
varies from 37 to 45 mm. Tensions between 30 and 
35 mm. indicate a mild degree of acidosis, below 30 mm. 



i Schloss, O. : Amer. Tour. Dis. of Children, xiii, 218, 1917. 
2 Marriott : Jour. A. M. A., lxvi. 1594, May 20, 1916. Howland 
and Marriott : Am. Jour. Dis. of Children, xi, 309, 1916. 



ACIDOSIS. 399 

a moderate, and below 25, a severe acidosis, and below 
20 mm. an extreme acidosis. 1 

More difficult, but more accurate are the determina- 
tions of the bicarbonate content of the plasma by the 
Van Slyke method. 2 The amount of C0 2 given off is 
measured after strong acids are added to a certain vol- 
ume of blood to liberate the CO- 2 . In infants the plasma 
contains 50 to 70 volumes per cent, of combined C0 2 . 
Adults have about 10 per cent. more. In infants amounts 
less than 45 indicate acidosis. The results, if multiplied 
by 0.7, approximate alveolar carbon dioxide tension in 
millimeters determined according to the method of Mar- 
riott. As mentioned previously, the excessive H ions 
stimulate respiration and the excessive acids in the blood 
decompose the carbonates so that C0 2 is blown off 
through the lungs, lowering the amount combined in the 
blood. Consequently, this test indirectly measures the 
available alkali reserve of the blood. 

Sellard's 3 test is to determine the alkali tolerance of 
the individual. Under normal circumstances, the inges- 
tion of small quantities of sodium bicarbonate by mouth 
increases the amount of this substance in the blood and 
the excess is rapidly excreted in the urine, causing the 
reaction of the urine to become amphoteric or alkaline 
to litmus temporarily. Marriott recommends the use of 
brom-cresol purple in 2 per cent, alcohol solution ; a 
drop or two of this solution is added to a small amount 
of urine in a test tube. This indicator changes from 
yellow to purple at about the normal reaction of the 
urine (PH G ). When the urine turns this indicator pur- 
ple, it indicates that acidosis is not present, or that the 
acidosis has been corrected. If the indicator does not 
turn purple, it may or may not mean the presence of 
acidosis. This is a simple test which can easily be com- 



1 I lowland and Marriott: Hull. Johns Hopkins Hosp., xxvii 63 
1916. 
-Van Slyke, D. I >. : lour. Biol. Chem. xxx, p. 347, June, 1917. 
SSellards: Johns Hopkins Hosp. Bull, xxv, 101, 1914. 



400 INFANT FEEDING. 

pleted in the office. An alkaline reaction of the urine 
can be brought about in normal infants by administering 
2 to 3 Gm. of bicarbonate, and in older children and 
adults by 5 Gm., usually within an hour after adminis- 
tration, this will change the indicator purple. In acid- 
otic states four to ten times as much is necessary, be- 
cause first the bicarbonate given must replenish the 
depleted alkali of the blood and tissues, before being 
excreted in the urine. 

Another method devised by Sellards 1 consists essen- 
tially in precipitation of the proteins from a small quan- 
tity of blood and adding a drop of phenolphthalein in- 
dicator to the evaporated filtrate. In acidosis, instead 
of a deep red color, a pink or no color is present. 

Tests for acetonuria only apply to certain special 
varieties of acidosis. (Acetone-body acidosis.) The 
presence of such bodies are, however, not sufficient evi- 
dence when taken alone for diagnosis of acidosis; the 
reverse, however, holds true in that their absence does 
not exclude its presence. 

Again, in special types of acidosis (increased produc- 
tion of organic acids or ingestion of strong mineral 
acids), there is an increased excretion of ammonia com- 
bined with these acids. Consequently, a quantitative esti- 
mation of the ammonia co-efficient in the twenty-four 
hour urine is a valuable test for acidosis. It should, how- 
ever, be remembered that in the presence of nephritis the 
ammonia excretion may be normal. 2 

The first three methods described are those most prac- 
tical for routine clinical investigation. 

Prognosis. The prognosis varies with the pre- 
cipitating etiological factors, the severity of the acidosis, 
and upon the underlying constitutional conditions. The 
result obtained is dependent first upon our success in 
the removal of exciting factors; second the overcoming 



i Sellards : Ibid. 

2 Henderson, Y. : Arch. Internal Med., xvi, 109, 1915. 



ACIDOSIS. 401 

of the intoxication; and third, so far as possible the re- 
lieving, or when possible, removal of the underlying 
factors. The early relief of starvation, by the institu- 
tion of the proper diet, counteraction of infection, and 
the neutralization of the acetone bodies, is all that is 
usually necessary in the mild types secondary to starva- 
tion and infection. In children suffering from recurrent 
vomiting, sources of focal infection should be removed. 
In the acute types associated with diarrhea the prognosis 
is grave. Diabetes and chronic nephritis must always 
be reckoned with as extremely serious factors. In cases 
of acute nephritis of moderate severity the prognosis is 
better. 

Treatment. The treatment of acidosis must first be 
directed to the prevention of a further production of 
more acids ; second, to replenishing the alkali reserve ; 
third, to the elimination of the acids and their salts; 
and fourth, to the treatment of the underlying factors, 
whether they be acute infections, starvation or organic 
diseases. 

Water Administration. Large quantities of water 
should be administered by mouth, if it is tolerated. 
When not retained, subcutaneous or intraperitoneal ad- 
ministration of normal saline or Ringer's solution is to 
be recommended, the latter as often as every six hours, 
if necessary, during the early treatment. The total quan- 
tity of all fluids given should be recorded daily and every 
effort made to administer maximum quantities. 

In the presence of acetone body acidosis glucose should 
be given in all cases except those due to diabetes. Three 
methods of administration are available: by mouth, rec- 
tum, or intravenously. By mouth, a 5 to 10 per cent. 
solution may be administered every two to four hours, 
in quantities depending upon the age of the child and the 
tolerance of the gastro-intestinal tract. By rectum, a 5 
per cent, solution is best employed, which may be ad- 
ministered intermittently at intervals of three or four 
26 



402 INFANT FEEDING. 

hours, quantities varying from 60 to 120 mils (two to 
four ounces) being used, or in young infants and older 
children who are not too restless the drip method may 
be used. When there is a tendency to return the glucose 
solution it may be necessary' to compress the buttocks 
for at least one-half hour after each administration. A 
careful record should be kept of all solutions adminis- 
tered by this method and so far as possible the retained 
fluid estimated. In most cases a liter can be adminis- 
tered in the course of twenty-four hours. For infra- 
venous use, 5 or 10 per cent, of glucose in Ringer's or 
normal saline solution may be used, depending upon the 
size of the child, from 60 mils in small infants, to 300 
mils in older children, may be injected at one time, to be 
repeated as indicated. 

Intraperitoneal Injection. For this purpose equal 
parts of 4 per cent, glucose solution and Ringer's solu- 
tion may be used, making a 2 per cent, glucose and 0.40 
per cent, saline solution. Stronger solutions are hyper- 
tonic. Fifty to 500 mils may be administered by the 
gravity method. 

Alkali Therapy. In our experience we have not fav- 
ored the use of alkalies in the types of acidosis due to 
concentration of ketone acids and this agrees with the 
more recent experiences of Marriott, 1 Gamble, 2 and 
Schloss. 3 Glucose rather than bicarbonate is the logical 
agent in the treatment of non-diabetic ketosis. The 
same is true of the lactic acid type. Marriott found that 
when sodium bicarbonate is given, the amounts of sodium 
and sodium ions in the blood are increased and this in- 
crease disturbs the balance between the sodium, calcium 
and magnesium ions. If administered sodium bicarbo- 
nate should be given by mouth or intravenously. By 



1 Marriott, W. McKim : Personal communication. 

2 Gamble, J. L., Ross, S. G., and Tisdall, F. F. : Transactions 
Amer. Ped. Society, 1922. 

3 Schloss, O. M. : Trans. Amer. Ped. Society, 1922. 



ACIDOSIS. 403 

mouth from 1 to 2 grams may be given at four-hour in- 
tervals, dissolved in water. For intravenous use a 2 per 
cent, solution is best employed as it is isotonic with the 
blood. The same amounts of solution can be adminis- 
tered intravenously as recommended for the administra- 
tion of glucose. 

Howland and Marriott found that the simplest indica- 
tion that sufficient alkali has been administered is 
evidenced by shifting of the reaction of the urine to 
normal. When it becomes amphoteric or alkaline to 
litmus, we may consider that a slight excess has been 
given. Further administration should then be withheld 
unless the urine again becomes more acid than normal. 
When the carbon dioxide tension of the alveolar air is 
above 30, recovery is usually spontaneous and soda is 
unnecessary. Edema, tetany and even convulsions have 
been noted following the administration of large doses of 
soda, more especially in young infants. These usually 
disappear with the cessation of the soda medication. 1 

Diet. While the administration of glucose as recom- 
mended may carry the patient over the first emergency 
period, insufficient amounts of carbohydrate are given 
in this way to meet its needs. Efforts should therefore 
be directed toward the further administration of carbo- 
hydrates by mouth as soon as the condition of the stom- 
ach permits. After a short period of rest, the time of 
which will be indicated by the ability of the stomach to 
retain inert fluids, which in most instances is not over 
six to twelve hours, further administration of sugars 
and cereals should be begun. Thick cereal pastes, to 
which cane sugar or maltose dextrose compounds have 
been added, are usually best retained. They may be 
given in small quantities at two-hour intervals, or at 



1 The treatment for convulsions due to an excess of sodium 
ion in the body consists in pushing water and the administration 
of magnesium sulphate intramuscularly or subcutaneously. (See 
Spasmophilia.) 



404 INFANT FEEDING. 

longer intervals with the administration of corn or maple 
syrup, or honey in teaspoon ful or larger amounts. 
Malted milk is often well taken. Milk chocolate and 
plain candy, such as caramels, are valuable and are 
usually well taken by children who have eaten them 
previously and have a liking for them. Various plain 
wafers sold on the market may be tried on the second 
day. Fruit juices and sirups, more especially orange 
juice, should be given in small quantities. If orange 
juice is retained, larger quantities, diluted with sweetened 
water, should be given and continued. Skim milk or, 
better, skim buttermilk can usually be given by the third 
day. Whole milk and fats should be withheld until the 
child is convalescent. 

Medical Treatment. About the only conditions re- 
quiring further medication are gastric and intestinal dis- 
tention and the retention of decomposing food in the 
intestinal tract, vomiting and syncope. 

To clear the intestinal tract milk of magnesia or some 
other mild saline laxative, together with enemata, are 
best. For vomiting in the presence of gastric distention 
lavage with a weak bicarbonate solution is often most 
beneficial. Small doses of carbolic acid (Vs to % 
minim.), administered at two-hour intervals for three 
or four doses, together with tincture opii camphorata 
for the relief of vomiting and restlessness, are indicated. 
In the presence of syncope it may be necessary to ad- 
minister cardiac and respiratory stimulants. 



PART IX. 
Anemias of Infancy, 



A proper knowledge of the normal blood picture in 
early life is necessary in order to recognize pathological 
changes in the anemias. 

In the blood of the new-bom we find the following: 

The hemoglobin ranges from 110 to 140 per cent, as 
a rule. The erythrocytes are increased to from five to 
seven million, or over. 

These findings begin to decrease usually by the fourth 
day and toward the end of the first month the hemo- 
globin content and erythrocytes have arrived at the usual 
level of infancy. Nucleated reds may be present up to 
the third to sixth day. The leucocytes are often increased 
up to 30,000, averaging 70 per cent, polymorphonuclears 
and about 20 per cent, lymphocytes. Within a few days 
the proportions quoted below as averages for infancy 
are more nearly approximated. Myelocytes may be 
present for a few weeks. 

In the infant's blood we find the following : 

A slight decrease of erythrocytes and hemoglobin be- 
low the adult level, may be present. The red cells range 
from 4.5 to 5.5 million; the hemoglobin from 70 to 95 
per cent. 

The leucocytes average about 12,000 or 13,000. There 
is a preponderance of lymphocytes (60 per cent, as com- 
pared with 30 per cent, at the 15th year), and a small 
number of polymorphonuclears (30 per cent, as com- 
pared with 70 per cent, at the 15th year). The transi- 
tionals average between 8 and 10 per cent. The reversal 
of these percentages occurs by the 6th year. 

(405) 



406 INFANT FEEDING. 

Definition. Anemia is characterized by a decrease of 
the erythrocytes or hemoglobin, or both, in the blood. 
The hemoglobin has the most important function of the 
blood elements, namely, carrying oxygen, and so its de- 
termination affords the most important method for ascer- 
taining the functional capacity of the blood. Not infre- 
quently infants have a pale appearance and are seem- 
ingly anemic, but an examination of their blood reveals 
a normal red count and hemoglobin content ; this phe- 
nomenon may be ascribed to an angiospastic pallor of 
the skin. 

Etiology. Anemia may develop from any of the fac- 
tors producing it in the adult, but it tends to follow in 
the wake of less severe causes and there is a tendency 
to more rapid recovery in the absence of constitutional 
anomalies. Probably the most frequent causes of ane- 
mia in infants are nutritional disturbances, directly or 
indirectly due to faulty dietary and iron metabolism. 
Rickets goes hand in hand with this group of anemias. 
Especial stress will be placed upon this group in the dis- 
cussion because of its relevant bearing upon nutritional 
disorders in infancy. Other common causes of infan- 
tile anemia are infections, both acute and chronic, and 
hemorrhagic conditions. 

A convenient working etiological classification of the 
causes of anemia in infancy follows: 
1. Congenital conditions resulting in defective blood 
formation. 
Diseases of the mother during pregnancy, due to 
improper diet, eclampsia, syphilis, tuber- 
culosis, diabetes, etc. 
Prematurity and other conditions with resulting 
hypofunction of the hematopoietic system. 
Developmental defects in the blood-making 
organs and glands of internal secretion 
(aplastic anemia, cretinism). 



ANEMIAS OF INFANCY. 407 

2. Primary Hemorrhage. 

3. Acquired. 

A. Conditions resulting in diminished blood forma- 

tion: 

Due to improper hygiene, with resulting dis- 
turbances of nutrition; 

Due to dietetic errors (unduly prolonged 
lactation), (athrepsia, rickets and scurvy) ; 

Diseases of the hematopoietic system (per- 
nicious anemia, splenic anemias, leuke- 
mia). 

B. Increased blood destruction, due to toxic causes : 

Bacterial toxines (acute and chronic infec- 
tions) ; 

Parasitic toxines ; 

Endogenous toxines (nephritis, hemolytic 
jaundice) ; 

Chemical poisons (arsphenamin, phosphorus, 
mercury) ; 

Roentgen rays. 

C. Secondary hemorrhages, due to degenerative 

blood-vessel changes as a result of the causes 
enumerated in Group 3. 

Diseases of the mother and fetus, tending to prema- 
ture birth, have a direct influence on the postpartum 
blood findings. The blood pictures, however, vary con- 
siderably, depending upon the etiological factors involved. 
There usually is a predominance of the regenerating 
blood cells which may be of the embryonal or post- 
embryonal type. 

The characteristic type of cells produced by the blood- 
forming tissues in the fetus are as follows, normally 
macrocytes, myelocytes and megaloblasts, and are pro- 
duced by the fetal blood-forming tissues. Incomplete 
types of cells, such as the microcytes, poikilocytes, poly- 
chromatophiles, and normoblasts, may be found in both 
the embryonal and post-embryonal stages. In the infant 



408 INFANT FEEDING. 

whose immature tissues have only recently been of the 
fetal type, a reversion to embryonal blood cells is a com- 
mon finding in the anemias of even moderate severity, 
and is of much less significance than of the same find- 
ings in adults. 

Anemia in the mother during pregnancy is a cause 
of anemia in the fetus at birth. This condition in the 
mother may result from improper diet, a severe acute 
disease suffered during pregnancy, or from constitutional 
diseases of the mother, as syphilis, tuberculosis, nephri- 
tis, etc. 

Striking is an anemia which develops quite regularly 
in prematures during the first three months of life. In 
contrast to full term infants, in the prematures there are 
a greater number of nucleated red blood corpuscles, a 
more frequent appearance of myelocytes during the first 
days of life, and a lesser absolute and relative leucocy- 
tosis. There is also a distinct and very early hemo- 
globin impoverishment of the blood, which reaches its 
maximum in about the third to the fourth month. In 
the premature and twins it may fall rapidly to 50 per 
cent, or lower. This anemia is usually of the chlorotic 
type, the color index being usually 0.4 to 0.6. These 
infants develop a severe secondary anemia following in- 
fections, etc., much more readily than full term infants, 
even in the later months of the first year. Kunckel 1 
believed that the chlorotic-like anemia of prematures 
was due to a disturbance in the hemoglobin metabolism 
as well as a deficient iron storage. Lichtenstein 2 be- 
lieved it due to a hypoplastic condition resulting from 
insufficiency of the hematopoietic organ. Hugounenq 3 
has shown that the greater proportion of the iron is de- 
posited in the fetus during the last three months of preg- 
nancy. The premature therefore fails to get the required 



i Kunckel: Zeitschr. f. Kinderh., vol. 13, 1915, 101. 

2 Lichenstcin : Svcnska, La Karesa As Kapets Handlinger, 43, 
No. 4, 1917. 

3 Hugounenq : Jahrb. f. Kinderh., 51, 121. 



ANEMIAS OF INFANCY. 409 

amount of iron deposited in its liver (iron depot). 
Twins must divide the iron which the mother can fur- 
nish and so also have a congenital deficiency. 

Congenital hypoplasia and imperfect development of 
the bone marrow, which prevents the hematopoietic tis- 
sues from properly functioning and producing sufficient 
vascular elements, may cause a distinct condition (aplastic 
anemia) or merely be a contributing cause in the de- 
velopment of various anemias in infants. Probably the 
reason some children develop severe forms of anemia 
and others only a slight degree under the same condi- 
tions, lies in a constitutional weakness of the blood pro- 
ducing organs of the former. Instances have occurred 
in which several children in the same family have pos- 
sessed hematopoietic organs which were not capable of 
functioning sufficiently, death or severe anemias result- 
ing. It is reasonable to assume that there may be con- 
geni tally deficient bone marrow just as there is congeni- 
tally deficient thyroid. 

In infantilism and congenital anomalies of the glands 
of internal secretion (cretinism) anemias are usually 
marked. In the former deficient development of bone 
and bone marrow is cause enough for the anemia accom- 
panying tbese conditions. 

Anemias following hemorrhage are of the secondary 
type with a tendency to reversion to the embryonal blood 
picture. The most common causes of early blood loss 
in infants are bleeding from the cord and intracranial 
vessels. Somewhat later melena, hemophilia and sepsis 
may become evident causes, and in the later months pur- 
pura and scurvy must be considered. 

Faulty hygienic surroundings may alone cause con- 
siderable anemia ; however, there are usually other asso- 
ciated factors. 

Lack of "mothering" and institutional overcrowding 
predispose to secondary infections. 



410 INFANT FEEDING. 

As mentioned previously, nutritional disturbances are 
the cause of the largest percentage of anemias in early 
life. There is nothing specific about the degree of ane- 
mia which a nutritional disturbance will cause. In some 
cases a severe degree of anemia will develop with a 
severe nutritional disturbance, in others the anemia will 
be slight and vice versa. From about the seventh month 
to the end of the second year (at the end of the nursing 
period) there are more anemias with relatively grave 
blood pictures than at any other age. It appears, there- 
fore, that there is a predisposition toward a functional 
insufficiency of the hematopoietic system at this age 
which predisposes to anemias. This is somewhat analo- 
gous to the diseases of the skeletal and nervous system 
of this period, namely, rickets and spasmophilia. Im- 
proper artificial nutrition, metabolic and gastro-intestinal 
disturbances and poor hygienic surroundings probably 
play an important role in the etiology. Premature in- 
fants, twins and those who have not completely recovered 
from previous hemorrhages are especially predisposed. 

Faulty feeding may produce anemia in several ways. 

First, there may be an insufficient amount of iron in 
the food. The new-born has an iron reserve or storage 
in his tissues of which the liver is the most important 
depot, which is highest at birth and then gradually falls 
until a minimum is reached at the end of the lactation 
period. This iron reserve prevents an iron deficiency 
while the infant is being fed on iron-poor milk. How- 
ever, if the iron-deficient food is fed over too prolonged 
a time, without the addition of mineral rich food to the 
diet, an anemia is prone to develop. Naturally, in some 
infants this condition develops sooner than in others, 
depending upon the original amount of stored iron sur- 
plus and the demand upon this reserve. 

Second, faulty feeding leading to chronic functional 
intestinal and metabolic disturbances may cause anemia. 
This may be due to lack of absorption of enough food. 



ANEMIAS OF INFANCY. 4H 

In most conditions of poor or impaired nutrition all the 
organs of the body suffer to some extent. Thus the 
bone marrow may function deficiently under these cir- 
cumstances and produce fewer erythrocytes, or erythro- 
cytes deficient in hemoglobin. 

Improper feeding may result in certain severe nutri- 
tional disorders, as rickets and scurvy. In these condi- 
tions the more or less severe anemia, which always 
accompanies them, may be due to the same etiologic 
factors (poorly balanced diet, improper hygiene, etc.) 
or result from the diseases themselves or both. Thus 
the hemorrhages in scurvy may lead to anemia and the 
pathology in the bone marrow of rickets interfere with 
its hematopoietic function. 

Of the causes of the primary anemias little positive 
information is at hand. They are, in all probability, toxic 
in nature with a secondary effect on the blood-making 
organs, and may be exogenous or endogenous in origin. 

The bacterial toxines are second only in importance to 
the nutritional disturbances as etiological factors in the 
production of secondary anemias. Among the most im- 
portant of the acute infections are diphtheria, scarlet 
fever, tonsillitis, pyelitis and otitis, and septic infections. 
Among the chronic, tuberculosis and syphilis play the 
most important role in infancy. Parasitic and chemical 
toxines are of far less importance in infancy than in 
older children, except those following arsenical poisoning. 

Among the endogenous toxines, those resulting from 
nephritis are frequent causes of secondary anemias. 

Iron Metabolism. The iron content of both human 
and cow's milk is small and not sufficient to meet the 
requirements of the developing infant. However, there 
is an iron depot in the. liver 1 in which is deposited 
enough iron by the time of birth to last until the infant 
can digest foods containing iron. If this original supply 
is abnormally small (as in prematures, etc.) or there is 



i Bur R e : Zcitschr. f. Physiol. Chemic, xiii, 399, 1889. 



412 ENFANT FEEDING. 

an unusual drain upon it (as in hemorrhages, infections, 
etc.), the supply may he used up hefore iron-containing 
foods are added to the diet. 

Human milk contains 0.00015 per cent, of iron and 
cow's milk about 0.0007 per cent. Iron is absorbed by 
the small intestine and excreted by the large intestine. 
Inorganic, as well as organic iron is easily absorbed. But 
the fact that iron given per os is absorbed into the cir- 
culation and excreted into the large bowel is not proof 
that iron is really used by the organism. However, the 
administration of iron medication per os has a markedly 
beneficial effect on certain types of anemia. 

In 100 Gm. of ash in the newborn there are about 
0.8 Gm. of Fe 2 3 ; 38 to 40 per cent, of this iron is in 
the blood ; the remainder is deposited in the tissues 
(Hugounenq). 1 The actual amount of hemoglobin in 
the body rises from birth, but the amount as compared 
with the body weight diminishes. The amount of iron 
deposited in the tissues, especially in the liver of the new- 
born, diminishes soon after birth. In other words, the 
iron in combination with hemoglobin, or the herao- 
chromogen radical, increases from birth, but the iron not 
so combined (reserve iron) diminishes. It is thus easy 
to understand why the new-born should have such a 
large amount of hemoglobin and reserve iron, and that 
this hemoglobin iron should increase, for the relatively 
great body surface in the new-born requires a large 
amount of oxygen-carrying material. Therefore a large 
amount of hemoglobin must be produced. The hemo- 
globin iron is increased at the expense of the non- 
hemoglobin iron. 2 

Symptoms. There are no special subjective symp- 
toms characterizing anemia in infancy. Many of the 
symptoms present can be attributed to the condition caus- 
ing the anemia. The majority of cases may be grouped 



1 Hugounenq: Jahrb. f. Kinderh., 51, 121. 

2 Schwarz, H. and Rosenthal, N. : Arch. Ped., 37, 1, 1920. 



ANEMIAS OF INFANCY. 413 

into two more or less defined types. The thin under- 
weight infants, who seem never to have thrived from the 
time of their birth — they are especially liable to nutri- 
tional disturbances and infections. The second group 
may be but little under weight and present a well rounded 
appearance ; however, on closer examination they show 
a more or less marked pallor, and in the extreme cases 
of the fat type, their skin is of a greyish or waxy yellow 
tint and at times seemingly semitransparent. The mucous 
membrane findings are of varying intensity and are of 
the same degree as those of the skin. The majority of 
cases belong to the second group and include many of 
the premature and rachitic infants and those with low 
grade infections. Edema occasionally appears about the 
face, trunk and extremities in the severe forms. The 
onset may be sudden, or gradual, depending upon the 
etiologic condition, i.e., sudden, following infections and 
hemorrhages; gradual, following nutritional disturbances, 
or again, as in prematures, it may be present from birth. 
Anorexia, listlessness and muscular weakness may be 
present. Occasionally the appetite may be capricious. 
The state of nutrition also varies with the cause. The 
infant may be considerably underweight although at 
first appearance this may not be evident. There may be 
gastro-intestinal disturbances. Hemic murmurs are not 
as frequent as in older children and adults. In the severe 
anemias, petechia? may occur in the skin and mucous 
membrane, but severe hemorrhages are unusual except 
possibly epistaxis. More severe hemorrhages may, 
however, occur following ulceration of other mucous 
membranes. 

Splenic enlargement associated with anemia is a very 
frequent finding during the first year of life and its 
presence is of great diagnostic value. Not infrequently 
there is an increased consistency with only moderate en- 
largement and again in (he presence of sepsis and other 
infections there may be a considerable enlargement but 



414 INFANT FEEDING. 

the spleen may be so soft that it is difficult to palpate. 
The spleen is usually considerably enlarged in the severe 
secondary anemias from all causes. It may decrease in 
size before the blood itself has reached normal levels. 
A large hard spleen in the first three months of life 
should lead to an examination for the presence of syph- 
ilis. Other common causes of splenic enlargement during 
the first six months are septic infection, tuberculosis and 
various types of subacute infections. The anemias due 
to various constitutional diseases, such as rickets and 
status thymico-lymphaticus, are usually associated with 
splenic enlargement. The most marked enlargements 
accompanied by anemia occur in von Jaksch's anemia, 
the leukemias, Banti's and Gaucher's diseases. Hemo- 
lytic jaundice is also accompanied by enlargement of the 
spleen. 

The enlargement of the liver, although not infrequently 
present, is rarely a predominating feature in the clinical 
picture. 

Hyperplasia of the lymph glands is directly dependent 
upon the underlying cause of the anemia. 

Blood Findings. The changes in the blood picture are 
the most important factors in the differential diagnosis 
of the anemias of infancy. 

In the simplest secondary anemias resulting from 
hemorrhage, infections (toxins) or nutritional disturb- 
ances, there is usually a reduction of both hemoglobin 
and erythrocytes to about the same degree. In the more 
severe forms, anisocytosis, poikilocytosis, polychromato- 
philia and normoblasts are not unusual. Usually very 
few embryonal (fetal) blood elements are found, such 
as megaloblasts, macrocytes, and myelocytes. The leuco- 
cyte count varies, depending on the causative factor. 

Following hemorrhage a relative leucocytosis is usu- 
ally noted. In the acute infections they vary according 
to the type of infection and the ability of the organism 
to react. Individual infants vary greatly in the response 



ANEMIAS OF INFANCY. 415 

of their hematopoietic systems to the same type of infec- 
tions ; in the acute septic infections usually an absolute 
increase in the neutrophiles is seen, while in tuberculosis, 
syphilis and influenza a low, white count and at times a 
leukopenia with an absolute increase of lymphocytes may 
be noted. Subacute and chronic focal infections often 
show little or moderate increase in the total count with 
a predominance of lymphocytes. 

The so-called chlorotic type of anemia — the common 
type seen in prematures, twins, and the poorly fed in 
the early months of life — probably has a similar founda- 
tion in many instances and presents the following blood 
changes : The hemoglobin is greatly diminished but the 
red count rarely falls below 3,000,000 and is more fre- 
quently between 4,000,000 and 5,000,000. The color 
index is usually between 0.4 and 0.6. The leucocyte 
count approximates the normal, ranging from 6000 to 
10,000. There is a varying tendency to lymphocytosis 
at times. However, this should not be misinterpreted 
because of the normal high mononuclear count in the 
young. The red cells only occasionally show poikilo- 
cytosis and anisocytosis. Nucleated reds are rarely 
found. Blood platelets range between 200,000 and 
300,000, the blood volume tends to remain normal and 
the spleen is usually not large. 1 

In the type described as von Jaksch's anemia, a con- 
dition occurring in infants and cbildren, a marked anemia, 
moderate enlargement of the liver, and great enlarge- 
ment of the spleen and sometimes hypertrophy of the 
superficial lymph nodes are present. The blood picture 
is characterized by a great diminution in the red cells and 
the hemoglobin, and a persisting leucocytosis of varying 
degrees. Nucleated red cells arc nearly always present, 
sometimes in large numbers, and occasionally myelocytes 
are seen. The hemoglobin is usually below 50 per cent. 



1 Schwarz and Rosenthal : Ibid. 



416 INFANT FEEDING. 

and may be as low as 15 to 20 per cent. The red cells 
are generally 2,000,000 to 3,000,000 per cram, but may 
fall to 1,000,000, or lower. There is a high grade aniso- 
cytosis, poikilocytosis and polychromatophilia. The leu- 
cocytosis usually ranges between 15,000 and 50,000. The 
small lymphocytes are usually greatly increased more 
especially in the cases secondary to nutritional disturb- 
ances. Occasionally this picture is reversed in the pres- 
ence of infection. The condition is most frequently 
associated with rickets, but whether cause or effect or 
concomitant is not known. It is most common during 
the sixth to the fifteenth month, the age at which rickets 
is most frequently seen in the active stages. It is rare 
in the breast-fed and well-nourished infants. Syphilis 
and possibly tuberculosis are believed to play a role in 
some of the cases. Upper respiratory infections, chronic 
pyelitis, endocarditis, and like infections may cause a 
similar picture. 

Most of the patients show a definite tendency to re- 
covery. The prognosis must necessarily be dependent 
upon the underlying cause and the presence of secondary 
complications.. In those who live, the abnormal blood 
picture may persist for a long period after the patient 
is clinically well. Gratz 1 regards it as an infantile form 
of Band's complex. His view has received but little 
support. There has also been a tendency to call this 
condition "anemia splenica infantum." This is, however, 
undesirable, as in its present use "splenic anemia" is a 
descriptive term which is applied to a large number of 
unrelated conditions. For practical purposes and until 
the condition is better understood, it is preferable to 
speak of it as "von Taksch's anemia," than "anemia 
pseudoleukemia infantum," the name originally given 



1 Gratz : Unter clem Bildc der Anemia splenica verlaufende ex- 
tra-medullare Bildnng von Blutzellen bei einem 3 jahrige Kind., 
Zentralb. f. allg. Pathol, u. pathol. Anat., 1909, xx. Cit. by 
Stettner. 



ANEMIAS OF INFANCY. 417 

to the condition, since the term pseudoleukemia has since 
acquired a more specific usage and the condition to which 
it refers is in no way related in so far as is known to 
this type. 

Pernicious Anemia. This form of anemia is very rare 
in infancy. Well authenticated cases have, however, been 
reported. The anemia is of the hemolytic type. The 
red blood cells are greatly decreased in number and the 
hemoglobin, being set free, results in a marked decrease 
in its content. There is, however, a high color index in 
which this blood picture is different from that seen in 
any of the other types of anemia. There are normoblasts 
present and a high percentage of megaloblasts. The red 
cells are altered in other respects, showing poikilocytes, 
microcytes and macrocytes. Leukopenia is present in the 
majority of cases and a relative lymphocytosis of above 
that to be expected in infancy is usually present. In 
extremely leukopenic blood a noteworthy finding is the 
abnormally high percentage of large mononuclear non- 
granular cells. Myelocytes are almost always present. 
The spleen and lymph glands are usually not much 
enlarged. 

Aplastic or hypoplastic anemia is dependent upon a 
congenital or acquired hypoplasia of the bone marrow. 
It is a rare condition and in its chief characteristics re- 
sembles pernicious anemia and is in all probability a 
form of this disease. The blood picture shows little effort 
on the part of the organism to reproduce the blood cells. 
It is characterized by a marked diminution in the hemo- 
globin and red cells. Regenerative forms of the blood 
cells are usually absent and a high grade leukopenia is 
usually present. The spleen more commonly shows 
moderate enlargement. 

Among the more exceptional types of anemia seen in 
the young and which are always associated with spleno- 
megaly are: Gaucher' s disease or primary splenomegaly, 
in which the greatly enlarged spleen shows masses of 



. 418 INFANT FEEDING. 

characteristic large vesicular cells with small eccentric 
nuclei, which block the sinuses of the spleen. Similar 
groups of cells are found in the lymph nodes, liver and 
bone marrow. It is characterized clinically by chronic 
splenomegaly, enlargement of the liver and a peculiar 
brownish or grayish discoloration of the skin. The ane- 
mia is usually of the chlorotic type and is more often 
of moderate degree. A diminution in the number of 
white cells is characteristic. It is probably congenital 
in origin, although usually not recognized until late in 
infancy or childhood. 

Hemolytic icterus. Two types have been described: 
The familial or Minkowski type, which is often seen in 
several members of the same family. The main symp- 
toms are an enlargement of the spleen and to a lesser 
degree of the liver. The most outstanding symptom is 
an acholuric jaundice. Increased fragility of the red 
blood cells is often marked and this condition must be 
classed as a true hemolytic icterus. 

The second type, which is known as the acquired or 
Hayem type, may come on at any age and is usually 
associated with a considerable anemia and a decided en- 
largement of the spleen and liver. Fragility of the red 
cells and acholuric jaundice are constant findings. These 
conditions usually last throughout life and often show 
little effect upon the general health. No specific lesion 
has been demonstrated at autopsy. 

Banti's disease or complex is discussed to complete 
the group but does not concern us in infancy, as it is a 
disease of later childhood and adults. Banti's complex 
and splenic anemia, as commonly described in the litera- 
ture, are probably one and the same thing. Moschcowitz 1 
believes that it is due to a fibro-genetic toxin, probably 
of intestinal origin, which attacks the organs draining 
the portal area, causing primarily a fibrosis of the spleen ; 



1 Moschcowitz, Eli : Jour. Amer. Med. Assn., box, 1045, 1917. 



ANEMIAS OF INFANCY. 419 

and if the toxin is sufficiently intense or the patient lives 
a sufficiently long time, it causes a cirrhosis of the liver. 
The sclerotic vascular changes in the mesenteric vessels 
are explainable on the same grounds. Finally, there de- 
velops an ascites due to atrophic changes in the liver. 
The course of the disease is slow, often covering a period 
of many years, with a gradually increasing weakness and 
pallor and digestive disturbances. A tendency to hemor- 
rhages with a moderate anemia of the chlorotic type is 
usually present. The resistance of the red cells is un- 
changed and signs of a regenerating bone marrow, as 
evidenced by nucleated and reticulated cells, are slight 
or absent. 

Leukemias while rare in infancy are of sufficient fre- 
quency to deserve mention. The types most likely to 
be seen are the acute forms. 

Acute lymphatic leukemia is the most common form 
in early life. The symptoms are usually so severe and 
the course so rapid as to suggest an acute infection. In 
most cases there .is a history of a preceding infection, 
such as tonsillitis, sinusitis, alveolar abscess, acute pul- 
monary infections, multiple abscesses, osteomyelitis, etc. 
Other cases develop in the presence of existing simple 
or secondary anemias, in the course of nutritional dis- 
turbances, rickets, scurvy, etc. Congenital syphilis has 
been described as a predisposing factor. Leukemia may, 
however, occur as a primary disease in infants previously 
healthy. 

The onset may be abrupt with several general symp- 
toms, as fever and prostration, or it may be more grad- 
ual, resembling a low grade infection. There soon 
develops a generalized glandular swelling, often first 
noticed in the cervical region, probably because the glands 
are more visible or due to the fact that they may be first 
involved when the source of (he infection is in the region 
of the upper respiratory tract. However, the axillary, 
epitrochlear, inguinal and femoral glands usually soon 



420 INFANT FEEDING. 

become involved, and roentgenographic studies will show 
involvement of the tracheal and bronchial glands and not 
infrequently the thymus. The glands vary greatly in 
size, from that of a pea to a walnut. They show little 
tendency to become tender and rarely suppurate. The 
spleen soon becomes enlarged, more often moderately, 
rarely reaching the size seen in the chronic forms. The 
liver is also enlarged in most of the cases. Doth of these 
organs, as well as the other parenchymatous organs, show 
a marked infiltration with lymphoid tissue, either diffuse 
or in patches. The changes in the bone marrow vary, 
being slight in some instances. The gums become swol- 
len and the findings in the mouth may resemble those 
of a severe scurvy. Bleeding occurs and not infrequently 
sloughing of the gums, tonsils and palate. Subcutaneous 
hemorrhages, petechial or larger ecchymotic areas, to- 
gether with bleeding from the mucous membranes of the 
nose, stomach, intestines and bladder, usually occur dur- 
ing the course of the disease. 

The blood picture varies in the different stages. In 
many instances great changes are noticed from day to 
day. At times there will be noted a considerable increase 
in white cells and this may change within a few hours 
to a leukopenia. The lymphocytes dominate the blood 
picture, often reaching from 90 to as high as 100 per 
cent, of the' white cells, with a corresponding reduction 
in the other forms. Most cases show a very high per- 
centage of the large type of lymphocytes. These cells, 
however, are frequently degenerate and offer great dif- 
ficulty in staining for differentiation. The total white 
count usually runs from 25,000 to 100,000 cells in 
infants. At times, and more especially toward the end 
of the disease, they may almost disappear. The hemo- 
globin may be reduced to 10 to 30 per cent, and the 
red cells to 1,000,000 to 2.000,000. The diminished 
coagulability of the blood accounts in part for the great 
susceptibility to hemorrhage. The disease is usually ac- 



ANEMIAS OF INFANCY. 421 

companied by an irregular temperature curve and evi- 
dence of myocardial involvement. 

The course usually covers a period of from two to 
four weeks from the time of its recognition, although 
some cases may run a longer course. 

Splenomyelogenous leukemia, while more rapid in its 
course in the young is less acute than the lymphatic type 
and is an exceptional disease in infancy. Anemia and 
splenic enlargement are usually the first signs to be noted. 
There is more or less evident involvement of the liver. 
The lymphatic glands rarely attain a large size and may 
not be visibly involved. Asthenia is marked and an 
early manifestation, and is associated with a rapid, weak 
pulse, dyspnea and disturbances of the digestive tract. 
Hemorrhages into the skin and mucous membranes may 
be present at any stage of the disease. The total white 
count is greatly increased, at times varying between 
50,000 and 500,000. The polymorphonuclear neutro- 
phils are greatly increased, although at certain stages 
they may be in greater part replaced by myelocytes. Both 
the mono- and polymorphonuclear types of eosinophils 
are increased. The lymphocytes are increased, the small 
cells oftener predominating. Increase in both the mono- 
and polymorphonuclear basophils is one of the most 
characteristic findings of the disease. 

The course of all forms of true leukemias of infants 
is toward a fatal termination. Most of the cases are 
complicated by secondary infections. 

Prognosis. In the anemias of infancy the prognosis 
is dependent upon the nature of the cause and the ability 
of the individual infant to react. In the milder types 
associated with improper diet, poor hygiene and rickets, 
with removal of the cause, improvement is usually rapid. 
\\\ those following acute hemorrhage of moderate de- 
gree, regeneration is usually rapid, unless there be some 
underlying constitutional condition, such as scurvy and 
purpura, when the prognosis must be guarded. In the 



422 INFANT FEEDING. 

acute and chronic infections, more especially diphtheria, 
tuberculosis and syphilis, it will vary with the severity 
of the infection, the individual resistance and the insti- 
tution of proper treatment. The same may be said of 
the cases following genito-urinary infections, such as py- 
elitis and nephritis. In the severe types of anemia asso- 
ciated with embryonal blood pictures, splenic enlargement, 
and grave constitutional involvement, the prognosis is 
always grave. In all types of anemia there is a tendency 
toward secondary infection due to lessened immunity. 

Treatment. The treatment must be directed toward 
removing or curing if possible the exciting etiological 
factors, as well as toward remedying the existing anemias. 

ProphylacticaUy, much can be accomplished toward 
preventing certain of the anemias of infancy. A com- 
plete clinical study of the patient must be made, including 
a thorough search for possible focal infections. The 
mouth, nose and throat, sinuses, respiratory, digestive 
and urogenital tracts must be carefully investigated. If 
any focal infection is found it must be thoroughly eradi- 
cated. The important part which alveolar abscesses may 
play in the secondary anemias, even in infancy, must not 
be overlooked. 

The anemias of prematures can often be avoided by 
proper feeding, the early administration of iron, cod- 
liver oil and orange juice, more particularly in the arti- 
ficially fed. The anemia resulting from nutritional 
disturbances can be prevented by a well balanced diet 
which includes prophylactic measures for rickets and 
scurvy. The instituting of vegetable soups and vegetable 
feeding as early as the sixth or seventh month, be- 
fore the iron reserve is completely exhausted, is to be 
recommended. 

The treatment of the anemia proper consists in ar- 
ranging the dietary, providing the age of the infant 
permits, so that plenty of iron containing foods are given. 
Especially valuable are green vegetables, vegetable and 



ANEMIAS OF INFANCY. 423 

cereal broths, meat juices, and eggs. Bread and cereals 
should be limited so as not to crowd out the above. Fruit 
juices are also valuable. Spinach in powdered form can 
be added to the milk mixture to advantage once or twice 
daily. 

Fresh air, sunlight, sufficient exercise and in general 
proper hygienic surroundings, are of tremendous im- 
portance. Hydrotherapy and massage may often be used 
advantageously. 

Iron and arsenic play the principal role in the medi- 
cation. A convenient form of iron medication is ferri 
et ammonii citrate, gr. ss to gr. iii, or the saccharated 
carbonate, grs. i to v, twice daily. In severer cases the 
hypodermic injection of iron, arsenic, or iron and arsenic 
combinations twice a week are recommended. The albu- 
minates or peptonates of iron may be alternated with the 
inorganic salts where the treatment must be long con- 
tinued. It should be remembered that there is a pos- 
sibility of over-medication with iron and that the stomach 
may rebel when excessive dosage is administered. Liquor 
potassi arsenitis, in 1 to 3 minim doses three times daily, 
is a valuable adjunct to iron medication but the period 
of time over which it is administered should be limited. 
Organotherapy and the administration of bone marrow 
have, on the whole, not yielded satisfactory results. 

Blood transfusion often proves extremely valuable in 
the severe forms of anemia. Intravenous transfusion is 
the most satisfactory, but good results have followed 
intramuscular injections of whole blood. Transfusions 
should be repeated at regular intervals in severe cases. 
The most that should be expected from transfusion is a 
temporary benefit in the severe cases sufficient to bridge 
the period of shock and the time necessary to the thera- 
peutic effect of other forms of medication. Prolonged 
exposure of the spleen to the roentgen rays, with proper 
protection of the surrounding tissue, has been followed 
by marked improvement in a number of our cases. 



424 INFANT FEEDING. 

In acute hemorrhage and some of the hemorrhagic 
diseases, physiological salt solutions, or better, Ringer's 
solution, intravenously or intramuscularly, may be in- 
dicated and in the former method of administration the 
addition of epinephrin to the solution is a valuable 
adjunct. 

Splenectomy for cases of von Jaksch's anemia, with 
good results, are reported by Giffin 1 and Stillman. 2 Five 
operative recoveries with apparently lasting improvement 
out of six cases are reported by them. With a tendency 
to spontaneous recovery in von Jaksch's anemia, the ad- 
visability of subjecting young infants, generally, to this 
operation is open to question. 



i Giffin, H. Z. : Annals of Surg., 42, 676, 1915. 
2 Stillman, R. G. : Amer. Jour, of Med. Sciences, xxx, 153, 
219, 1917. 



Appendix. 



PROPRIETARY BABY FOODS. 

It should be borne in mind that the average daily cost 
of many of the proprietary baby foods is in excess of 
twenty-five cents. 

For practical purposes the baby foods may be classed 
as follows: 
Group I. Prepared from cow's milk. 

1. Condensed milk without added sugar. 

2. Condensed milk with added sugar (Borden's 

Eagle Brand) (F., 8.85;' P., 7.34; milk-sugar, 
11.61; cane-sugar, 42.9; ash, 1.77; water, 27.53). 

3. Evaporated milk (St. Charles) (F., 9.0; P., 7.82; 

milk-sugar, 11.19; ash, 1.71; water, 69.91). 

4. Peerless Brand unsweetened evaporated milk (F., 

9.27; P., 7.28; milk-sugar, 9.99; ash, 1.51; water, 
71.82). 

5. Carnation Brand. 

6. Lacta Prseparata (powder). 

7. Mammala (powder) (F., 12.12; P., 24.35; milk- 

sugar, 55.34; ash, 5; moisture, 3.19). 

8. Dryco Brand powdered milk (F., 12.0; P., 34.0; 

milk-sugar, 44.0; ash, 7.0; moisture, 3.0). 

9. Klim (Merrell-Soule Co.) Powdered milk — mar- 

keted as whole milk powdered, skim milk pow- 
dered, modified milk powdered. 
10. Powdered albumin milk, Hoos albumin milk (pro- 
tein milk), Merrell-Soule protein milk (albumin 
milk). 

(425) 



426 INFANT FEEDING. 

Group II. Foods prepared from dried cow's milk and 
modified cereals. To be diluted with water only. 

(A) Containing much unchanged starch. 

1. Nestle's Food (milk-sugar, 7.4; maltose, 15.6; 

cane-sugar, 24.77; starch, 17.31; protein, 10.92; 
dextrin, 13.51; fat, 5.63; ash, 1.49; water, 
3.37). 

2. Anglo-Swiss. 

(B) Starch largely converted into soluble carbohy- 

drates, such as maltose and dextrin. 

1. Horlick's Malted Milk (F., 8.5; P., 16.3; dextrin, 

18.80; maltose, 39.15; lactose, 10.0; sodium bi- 
carbonate, 1.0). 

2. Allenberry's I and II. (No. I, F., 17.2; P., 10.6; 

maltose, 14.0; dextrin, 10.0; lactose, 42.0; ash, 
3.0.) (No. II, F., 15.88; P., 9.90; maltose, 
20.0; lactose, 36.0; dextrin, 13.0; salts, 3.71.) 

Group III. Foods prepared from modified cereals to be 
used with fresh cow's milk. 

(A) Starch unchanged. 

1. Flours of barley, wheat, rice, corn, oats, soy 

beans, etc. (Barley flour, 1 level tablespoonful 
(98 grains) to 12 ounces water equals 1.27 
starch or 1.8 calories per ounce.) 

2. Arrowroot. 

(B) Starch partially dextrinized. 

1. Barley flour: Robinson's, Mead's, Johnson's. 

2. Imperial Granum (F., 1.4; P. 14.0; carbohydrates 

(sol.), 1.8; carbohydrates (insol.), 73.5; ash, 
0.39; water, 9.0). (Can be used when flour ball 
•is indicated.) 

3. Eskay's Food (contains a small amount of egg 

albumin) (F., 1.0; P., 6.7; carbohydrates (in- 
sol.), 21.21; carbohydrates (sol.), 67.81; 
ash, 1.3). 



APPENDIX. 427 

4. Denno's Baby Food (F., 1.79; P., 11.0; cane- 

sugar, 15.2; starch, 64.6; ash, 1.12; water, 
6.2). 

5. Allenberry's No. Ill (malted) (F., 1.05; P., 

10.23; carbohydrates (sol.), 25.00; maltose, 
16.5; dextrin, 8.5; carbohydrates (insol.), 
60.01; ash, 0.60). 

(C) Starch completely changed to dextrin and 
maltose : 

1. Borcherdt's Dri-Malt Soup Extract (maltose, 

71.10; dextrin, 13.50; protein, 8.66; ash, 2.94; 
moisture, 3.80). Calories per ounce by weight 
equals 110. It is a laxative, and is easily di- 
gested because of the high maltose and potas- 
sium carbonate (1.1 per cent.) contents. 

2. Borcherdt's Malt Soup Extract (protein, 6.40; 

maltose, 57.57; dextrin, 11.70; ash, 2.54; mois- 
ture, 21.79). It contains 1.1 per cent, potas- 
sium carbonate. 

3. Borcherdt's Dri-Malt Soup Extract with Wheat 

Flour. Semi-liquid malt soup extract, to 
which gelatinized wheat flour has been added, 
and the whole dried. One ounce equals 110 
calories. 

4. Borcherdt's Malt Sugar (dry) (maltose, 87 per 

cent.; dextrin, 5 per cent.). One ounce equals 
120 calories. The following table will give a 
comparative idea of the relative value by weight 
and measure of Borcherdt's liquid and dri-malt 
soup extracts : 
16 Fluid oz. equal 19.5 oz. dry malt powder by measure. 

1 Fluid oz. equals 1.2 oz. dry malt powder by measure. 

1 Ounce of liquid by weight equals 0.83 oz. of powder. 

1 Fluid oz. represents 90 calorics. 

1 Ounce of powder by weight represents 110 calories. 



428 INFANT FEEDING. 

5. Horlick's Malt Food (contains no milk) (F., 1.40; 

P., 12.06; carbohydrates (chiefly maltose), 
81.97; ash, 2.60; water, 1.97. Calories, 109.29. 
It contains 1 per cent, of potassium bicarbonate. 

6. Mellin's Food (F., 0.16; P., 10.35; maltose, 

58.88; dextrin, 20.69; carbohydrates (sol.), 
79.57; salts, 4.3; water, 5.6). Calories, 91.43. 
It contains 2 per cent, of potassium bicarbonate. 

7. Dextri-maltose (Mead's No. 1) (maltose, 52; 

dextrin, 41; water, 5; sodium chloride, 2). No. 
2 (maltose, 53; dextrin, 42; water, 5). No. 3 
(maltose, 52; dextrin, 41; water, 5; potassium 
carbonate, 2). 

8. Nahrzucker (Sohxlet) (F., 0.03; P., 0.13; mal- 

tose, 41.0; dextrin, 53.3; ash, 1.7; water, 2). 

Group IV. Dry casein. 

1. Larosan (Roche), (calcium caseinate). 

2. Casec (Mead), (calcium caseinate). 

3. Protolac (Dry Milk Co.), (calcium caseinate). 

Group V. Diastatic ferments. 

1. Diastoid (Horlick's, powder). Maltose 72.91 per 

cent. 

2. Diazyme (Fairchild, liquid), a good product. 

Group VI. Peptonizing powders. 

1. Peptogenic milk powder (Fairchild's). 

2. Pepsin. 

Group VII. Rennet powders (precipitating curd in a 
finely divided form). 

1. Chymogen (rennin and milk-sugar). 

2. Pegnin (rennin and milk-sugar). 

Group VIII. Powdered vegetables. 

Carrot (Beebe). 

Spinach (Beebe). 
It will be noticed that there are two great classes of 
proprietary infant foods : 



APPENDIX. 429 

The First. (Groups I, II). Those containing cow's 
milk. 

Sweetened Condensed Milks. These are advertised as 
complete infant foods. All of them are quite similar in 
composition. All contain large amounts of cane-sugar. 
It is impossible to make, by simply adding water, a 
properly balanced food for an infant's continuous diet. 
A dilution to give a rational amount of proteins and fats 
has a large excess of sugars, and one to contain any 
amount under 7 per cent, total sugar would be so weak 
in both protein and fat that the baby's proper growth 
would be very seriously interfered with. 

Eagle Brand condensed milk contains : fat, 8.85 ; pro- 
teins, 7.34; milk-sugar, 11.61; cane-sugar, 42.90; ash, 
177; water, 27.5. 

TABLE. 

A Well-known Condensed Milk, Showing the Content 
of Various Dilutions. Fats and Proteins Deficient. 

Full 6 parts 12 parts 18 parts 

strength water water water 

Per cent. Per cent. Per cent. Per cent. 

Fat 6.94 .99 .53 .36 

Proteid 8.43 1.2 .65 .44 

Cane-sugar . . . 50.69 7.23 3.90 2.67 

Salts 1.39 .17 .10 .07 

Water 31.30 90.49 94.80 96.46 

The Unsweetened Evaporated Milks. They are made 
by heating the milk to 200° F., and then transferring it 
to vacuum pans, where it is maintained at a temperature 
of 125° F., until sufficient water is evaporated to bring 
the product to the required condensation. In most 
products this milk is about double strength. 

The sugar content not being in excess, these milks can 
be so diluted that a reasonable amount of fat and protein 
can be obtained, with, however, a considerable deficiency 
in sugar; this relatively low amount of carbohydrate can 
then be made up by adding sugar (cane or maltose-dex- 
trin compounds), much the same as is done with cow's 



430 [NFANT FEEDING. 

milk. Where it is impossible to obtain clean, fresh milk, 
evaporated milk can be used with good success as a tem- 
porary diet in traveling, etc. A fresh can should be 
opened daily. It can be diluted with three to six or more 
parts of water, or cereal water and sugar in some form 
as indicated; however, the carbohydrates contained in 
the formula should rarely exceed 7 per cent. One part 
of milk to two parts of diluent plus carbohydrates is the 
strongest formula in which it is ever necessary to feed 
infants, as this equals the strength of whole milk with 
carbohydrate added. 

Occasionally, infants with a very weak digestion will 
thrive on the evaporated milk where all other methods 
fail, if the food is started in high dilution, the quantity be- 
ing increased as the infant shows improved capacity. 

Because of the repeated heating and the low salt con- 
tent, the food necessarily loses some of its vital require- 
ments, and an early attempt to change to fresh milk 
should be made in order to avoid constitutional disorders 
as rachitis, scurvy, etc. The tendency to become very 
fat on this class of foods is proverbial, but this is not 
usually associated with high resistance or immunity to 
infections, and these infants succumb rapidly to the 
respiratory and intestinal infections. Unless the mother 
is forewarned, it is often with reluctance that she can be 
made to foresee the necessity of taking her baby off the 
food which agrees with it, and experiment with a new 
and occasionally uncertain formula. 

The Powdered Milk Foods. Mammala, Honor Brand, 
and Merrill-Soule Brand are fresh milk dried. In the 
two former, part of the cream has been removed. All 
have some lactose added. They find their most impor- 
tant indication as an occasional substitute feeding in 
breast-fed infants — first, for the mother's convenience, 
to allow her recreation ; secondly, where the milk of the 
mother is insufficient, and one or two regular feedings 
are indicated temporarily until a formula of fresh milk 



APPENDIX. 431 

is advisable, or while traveling, when the milk supply is 
uncertain; and thirdly, those containing large amounts 
of maltose (Horlick's) can be given once daily in breast- 
fed infants in need of a laxative. 

The Second Class. Those to be used in conjunction 
with fresh cow's milk. In this class belong Groups III 
and IV. These give us a far more rational infant food. 

Group III. (A) The unchanged or partially dextrin- 
ized starches are especially to be used in solution in place 
of boiled water as diluents, best after the second month. 
A number of good cereal flours can be purchased on the 
market. 

(B) In this group are found most of the highly ad- 
vertised and detailed baby foods. They have little or 
no advantage over the plain cereal flours. 

(C) These are especially valuable where maltose and 
dextrin are better taken than cane- or milk- sugar. Dex- 
tri-maltose (Mead's No. 1 and 2) and Nahrzucker. 

DIRECTIONS FOR THE PREPARATION 
OF INFANT'S FOODS. 

Tea. 

To a small half-teaspoonful of fennel, chamomile, or 
"green" tea add 1 pint of boiling water, cover with a 
clean dish, and steep for two or three minutes, or till the 
tea is of a light yellow color; then pour through a clean 
sieve or muslin. It should be weak. If used for thirst 
only, in diarrheal cases, one-fourth of the above amount 
is sufficient. 

Barley Water. 

Soak 2 tablespoonfuls of washed barley (pearl) in 
water overnight; pour off water, add 1 quart of fresh 
water, and boil down to 1 pint (2 hours). Add boiled 
water to make 1 pint, if necessary. Strain through fine 
cloth. Keep in ice-chest. 



432 INFANT FEEDING. 

Oatmeal and Rice Water. 

They are prepared in the same manner, only boiled 
more slowly. They may be made from barley, oatmeal, 
or rice flours by using 1 rounded tablespoonful to \y 2 
pints of water, and boiling for 20 minutes down to 1 
pint, in an open stew-pan, stirring constantly. (Ap- 
proximates 3 calories per ounce). In preparation of a 
feeding formula they can be prepared in a more con- 
centrated form if indicated. 

Farina, Cream of Wheat, Oatmeal and Rice 
Flour Gruels. 

To make six ounces use — 1 tablespoonful cereal, y 2 
cup water, y 2 cup milk, 1 pinch salt. Boil for- thirty 
minutes over the direct flame or l l / 2 hours in the double 
boiler. 

To Dextrinize Barley or Oatmeal Water. 

Cool to 105° F., add 1 teaspoonful extract of malt, 
cereo, liquid taka-diastase or diazyme, stir, allow to 
stand for 15 minutes, when the gruel becomes thin and 
watery. Add a pinch of salt, stir, only to mix, cool, 
strain, and put in ice-chest. 

Flour Ball. 

Tie 2 pounds of wheat flour in a cheese-cloth bag, and 
boil in 2 quarts of water for five hours. Remove from 
water; place in oven until quite brown on the outside. 
This will require from two to three hours slow baking. 
Break open and throw away the brown shell; the re- 
mainder, the baked flour, must then be grated into a 
powder, or may be ground in a mill. 

Albumin Water. 

To y 2 cup of cold boiled water add the white of 1 fresh 
egg and a pinch of salt. Stir very thoroughly. A piece 



APPENDIX. 433 

or two of artificial ice may be added before stirring. 
One-half teaspoonful of sugar and orange juice may be 
added, if not contraindicated. Barley water may be used. 

Albumin Water with Beef Extract. 

One-quarter teaspoonful of beef extract may be added 
to the cold water before adding the egg albumin. 

White of Egg and Digested Gruel. 

Whites of 2 eggs may be added to 1 pint of dextrin- 
ized barley, oatmeal, etc., gruels. Stir thoroughly. 

Pasteurization of Milk Without a Thermometer. 

Place milk as it comes from the dairy (with stopper 
removed and plug of sterile cotton inserted) in a pan of 
cold water with folded napkin beneath the bottle to pre- 
vent unequal heating. Let the water boil for three 
minutes. Allow to remain in hot water for eight minutes. 
Cool. 

Pasteurized Milk (double boiler). 

Place milk in cold water bath, having water to level of 
milk; bring milk to temperature between 155° and 
167° F. for 15 to 20 minutes. 

Sterilized Milk (double boiler). 

The milk mixture is put into the inner vessel cold, and 
the water in the outer vessel is also cold. The double 
boiler is then placed on the stove and allowed to remain 
until the water in the outer vessel boils for 6 to 8 min- 
utes; the whole process requires 10 to 15 minutes. 
While the milk heated in this manner forms a much finer 
and softer curd than that of raw milk, it is not as fine 
as the milk boiled directly over the flame. 

28 



434 INFANT FEEDING. 

Whey. 

Heat 1 quart of clean raw milk to 104° F., and add 1 
level teaspoonful of chymogen or fresh essence of pep- 
sin (Fairchild's). Allow it to stand for one-half hour, 
pour off the free whey, pour the curd into a straining 
cloth for one-half hour, and collect the remainder of the 
whey. 

Chymogen Milk. 

Boil milk for five minutes, cool to 104° F., and add 1 full 
teaspoonful of chymogen to each quart of milk, and stir 
for one-half minute. Let it come to a clabber by allow- 
ing it to stand for 15 minutes; then beat it well until the 
curd is finely divided. Do not heat above 100° F., when 
preparing individual bottles for feeding, otherwise curds 
will clump, and will not pass through the nipple. 

Indications for chymogen milk: (1) Vomiting in in- 
fancy; (2) indigestion due to the large curd formation. 

Buttermilk in the Home. 

A pure culture of lactic acid bacilli is added to raw, 
pasteurized, or boiled milk in an earthenware dish, and 
allowed to stand at about 80° F. for 15 to 20 hours, or 
until the casein is coagulated. Stir vigorously in a churn, 
or with a spoon or egg-beater until the curd is very small, 
and then push the contents through a fine wire strainer 
with a spoon. If the buttermilk is too thick, add a small 
amount of water. When the buttermilk is once made, 
a small portion (about 4 ounces) may be used as the in- 
oculating agent for the next supply to be made. In this 
way the original culture may be made to last from six 
to eight days. The quality and action of the product 
made will vary but little. Add 4 ounces of buttermilk to 
1 quart of fresh milk, incubate, and follow the above 
outline. Sometimes the milk will not coagulate, although 
it may smell sour. Stirring with a spoon will often pro- 



APPENDIX. 435 

duce coagulation in a few minutes. The fat present will 
rise to the top, and when coagulated appears as a brown- 
ish-yellow scum, which may be removed before the curd 
is broken up. At the present time the market is flooded 
with tablets for the preparation of buttermilk, but one 
must hesitate before using them to prepare milk for a 
baby. A pure culture should be used, or one recom- 
mended by the physician. Whole or skim milk is to be 
used as indicated in each individual case. 

Startoline. 

Carefully pasteurize 2 quarts of fresh whole milk to a 
temperature of 180° F. for one hour, or boil for five 
minutes ; cool quickly to about 80° F., and add 1 ounce 
of Hanson's Lactic Ferment Culture, and let it stand un- 
disturbed until well curdled, which should be in 15 or 20 
hours, at a temperature of 75° F. Then place on ice. 
When ready to use, beat curd up with a spoon until it is 
of a creamy consistency. 

Buttermilk for Hospital Feeding. 

Pasteurize whole sweet milk to a temperature of 180° 
F. for one hour; then place in cold water until cooled to 
80° F. Add 1 ounce of startoline to every quart of milk, 
stir with a spoon, and cover; allow to stand from 15 to 
20 hours, then churn for one hour ; then add a little cold 
sterile water to break butter away from milk; and strain 
buttermilk. 

Buttermilk and Skim Milk Mixture. 

To a few tablespoonfuls of buttermilk or skim milk 
add 2% level tablespoonfuls of flour (flour ball or dex- 
trinized barley flour), to make a paste. Make up to 1 
quart with buttermilk. (1) Bring to a boil, withdraw 
from fire. (2) Bring to a boil, withdraw from fire a 
second time. (3) Add 4 level tablespoonfuls of cane- 



436 INFANT FEEDING. 

sugar, and bring to a boil for the third time. (Maltose- 
dextrin preparations are best in all diarrheal conditions.) 
(1, 2, and 3 should require about twenty minutes time.) 
Make up to 1 quart with boiled water, if it has boiled 
away; put on ice. It is well to start with one-half the 
amount of sugar, and increase as indicated. 

Indications for buttermilk and skim milk mixtures : 

1. Fat indigestion. 

2. Loose bowels (it may be necessary to reduce the 

amount of sugar. The high protein contents 
tend to constipate). 

3. Malnutrition, with stationary weight. 

Brady's Mixture No. 1. 

Dr. Jules Brady, of St. Louis, has suggested the two 
mixtures following, which contain less carbohydrates 
than the above buttermilk mixture, and which he has 
found especially valuable in the feeding of infants in 
institutional practice. 

Mixture No. 1, which is used for young infants during 
the first two months, contains 11 calories in each ounce; 
the young infant receives 4 ounces of this mixture for 
every pound of body weight as soon as it will take it. 
The baby weighing 6 pounds at birth is allowed to take 
24 ounces in twenty-four hours, or 3.5 ounces every three 
hours, 7 feedings in twenty-four hours. The average in- 
fant at three or four days will take 1 ounce; at eight 
days, 1 to 2 ounces; at fourteen days, V/ 2 to 2 ounces; 
at three weeks, 2 ounces ; at six weeks, 3 ounces ; at eight 
weeks, 4 ounces. 
Mixture No. I. 

24 quart buttermilk or skim milk. 

*4 quart barley water (thick). 

1 ounce by measure, Mellin's Food. 

l / 2 ounce granulated sugar. 



APPENDIX. 437 

The ingredients are mixed together in the following 
manner: To the barley gruel is added the cane-sugar 
and the Mellin's Food, and then the milk is slowly added, 
and the mixture strained. As a rule, the milk is acidi- 
fied with lactic acid bacilli twelve hours before being 
made up, having first agitated it. 

Brady's Mixture No. 2. 

On reaching a weight of Sy 2 to 9 pounds, infants re- 
ceive the mixture No. 2, which contains 18 calories for 
every ounce. The babies are allowed 3 ounces of the 
mixture No. 2 for every pound of body weight. 

Mixture No. 2. 

% quart whole fresh milk or whole buttermilk. 
Y s quart barley water (thick). 
1 ounce granulated sugar. 

Keller's Malt Soup. 

To 11 ounces (330 Gm.) of warm milk gradually add 
1% ounces (50 Gm.) of flour, stir constantly, then pour 
through a clean sieve or muslin. In another dish dis- 
solve 3 ounces (100 Gm.) by weight, or 2y 2 ounces or 
tablespoonfuls by measure, of Borcherdt's malt extract 
with potassium carbonate in 20 ounces (600 Gm.) of 
boiled warm water. Then mix both solutions, put on 
fire, stir continuously, and boil for two or three minutes. 

Indications for Keller's Malt Soup : 

1. Fat indigestion. 

2. Disturbed metabolic balance (fat-soap stools). 

3. Chronic constipation (often relieved by simple 

addition of malt soup extract to ordinary milk 
mixture in place of part of sugar). 

Contraindications: 

1. Before the third month, if the stools are loose. 



438 INFANT FEEDING. 

2. For a period of more than four to eight weeks 
(to be followed, where possible, by ordinary 
milk mixtures, the strength of the latter being 
gradually increased). 

Cream Soups. 

Cream soups may be made from vegetable pulp, using 
1 tablespoonful of cooked potatoes, peas, or asparagus to 
Yz cup of water in which the vegetables were cooked, y 2 
cup of sweet milk, and l /i teaspoonful of flour, with a 
little butter and salt. Cook another minute or two. 
Strain if necessary. Serve. 

Corn or tomatoes may be used in the same manner, 
using 2 tablespoonfuls of strained vegetables, with 
about one-third water and two-thirds milk. When 
tomatoes are used, add a small pinch of soda to tomatoes 
before adding other ingredients. 

Vegetable Soup. 

One-fourth pound lamb stew, cut into pieces, 1 potato 
cut into pieces, 1 carrot cut into pieces, 2 stalks of celery 
cut into pieces, 1 tablespoonful of pearl barley, 2 table- 
spoonfuls rice, 2 quarts water. Boil down to 1 quart; 
boil three hours. Add pinch of salt, and strain before 
feeding. 

Lamb, or Veal Broth. 

Lean meat chopped fine, 1 pound; cold water, 1 quart; 
a pinch of salt ; cook slowly two or three hours to 1 pint. 
Add water from time to time, so that when finished there 
will be 1 pint of broth. Strain ; when cold, skim off fat. 

Chicken Broth. 

Small chicken, or one-half of large fowl, with all skin 
and fat removed ; chop bones and all into small pieces ; add 
1 quart boiling water and a little salt; cover closely, and 



APPENDIX. 439 

allow to simmer over a slow fire for two hours. After 
removing allow to stand one hour; then strain. Add 
water, if necessary, from time to time, so that there will 
be 1 pint when finished. 

Farina Soup. 

To 1 pint of meat broth, gradually add, while stirring, 
1 even tablespoonful of farina, and boil down to 1 cup 
(yH pint) in about twenty minutes. It is a good plan to 
boil the farina for from fifteen to twenty minutes before 
adding it to the broth ; then broth and farina need to be 
boiled together for but ten minutes. 

Dried Fruit Soup. 

Wash thoroughly 1 cup of dried apricots and 1 cup of 
prunes. Cook in 1 quart of cold water until very soft. 
Strain and press out all juice. Sweeten to taste. Thicken 
with a tablespoonful of rice flour to 1 quart of the liquid. 
Cook twenty minutes to remove the raw taste of the 
flour. 

Soy Bean and Condensed Milk (Ruhrah). 

Add a level tablespoonful of soy bean flour to 2 level 
tablespoonfuls of barley flour, add a pinch of salt, and 
mix to a paste with boiled water, adding further water to 
1 quart. Boil for twenty minutes, and add water to make 
up for the loss due to evaporation during boiling, so that 
total mixture is 1 quart. Condensed milk is now added, 
varying in quantity from J^ to 1 dram of condensed- 
milk to each ounce of the mixture, depending upon the 
age and the condition of the infant. Double the quantity 
of soy bean and barley flours may be used for older chil- 
dren. Each ounce of soy bean gruel contains 10 grams of 
protein and 102 calories. Two ounces of soy bean gruel 
in a quart of water contains 0.56 per cent, protein, 0.62 
per cent, fat, and 3.31 per cent, sugar. 



440 INFANT FEEDING. 

The quantity of the feedings may be varied according 
to the condition and needs of the infant, varying from 1 
to 8 ounces per feeding. 

It is indicated whenever fresh clean milk is not ob- 
tainable, in infants with marasmus, in some intestinal 
disturbance associated with diarrhea. 

Beef Juice. 

Take J4 to x /i pound round steak, broil slightly, cut 
into small pieces, and then press out the juice with a meat 
press or potato ricer, and add a small pinch of salt. Feed 
fresh, or warm before giving, but do not heat sufficiently 
to coagulate albumin. 

Potatoes. 

Boil potatoes in salt water in the ordinary way until 
they are thoroughly done. Then mash through a very 
fine sieve, and add a little butter. 

Spinach. 

Cook spinach in salted water until tender. Pour cold 
water over it, and drain. Chop fine, or rub through a 
coarse sieve. To 2 tablespoonfuls of spinach add 1 tea- 
spoonful of fine breadcrumbs, Y^ teaspoonful melted but- 
ter, and a little salt. Reheat and serve. 

Asparagus. 

Cook one-half of a bunch of asparagus in about a pint 
of slightly salted water. When tender, remove stalks one 
by one. Place on a warm plate, and remove pulp by 
taking hold of the firm end of the stalk, scraping lightly 
with a fork toward the tips. Use pulp only. Make a 
sauce with one-fourth of a cup of water in which 
asparagus was cooked, one-fourth of a cup of milk, 1 
teaspoonful flour, a little butter and salt. Dip a small 
piece of toast in the sauce. Take what is left of the 



APPENDIX. 441 

sauce and mix with 2 tablespoonfuls of asparagus pulp. 
Reheat. Place on toast and serve. 

Carrots. 

Cook y 2 pound of young carrots in a pint of fat-free 
soup stock or slightly salted water, adding more if it 
cooks away before they are done. Rub through a sieve ; 
add 1 teaspoonful of bread-crumbs, a little butter and 
salt. Reheat and serve. 

Beans. 

Soak 2 ounces or 4 tablespoonfuls of beans, and cook 
them slowly in a good deal of water until they are soft, 
but not broken. Rub through a sieve, add 1 cupful of 
soup stock, and let them cook for one-half hour, adding 
more stock if it boils away. Mix a little butter and flour, 
about a teaspoonful of each, and a little salt. Add to 
soup. Return to fire, and cook for a few minutes. 

Green Peas. 

Cook a cupful of green peas in boiling salted water 
until they are done. Drain, saving the water in which 
they are cooked. Rub through a coarse sieve. Make a 
sauce of 2 tablespoonfuls of water in which the peas 
were boiled, 2 tablespoonfuls of sweet milk, y 2 teaspoon- 
ful flour, y 2 teaspoonful fine bread-crumbs. Mix all 
together. Reheat and serve. 

Fruits. 

(a) Orange Juice: Take sweet orange, cut into halves, 
and squeeze out juice by hand or with a lemon squeezer; 
strain, put on ice, and use as ordered. 

(b) Prune Juice: Take y 2 pound of prunes, wash 
thoroughly, cover with cold water, and soak overnight. 
In the morning place on stove in the same water, and 



442 INFANT FEEDING. 

cook until tender. Add 1 teaspoonful of sugar, and 
strain. 

(c) Prune Jelly: Cover 1 pound of prunes with 1 
quart of water; cook slowly until tender; pit, and press 
pulp through a sieve. Add sugar to sweeten (2 tea- 
spoonfuls) and l /> box of gelatin dissolved in a pint of 
water, and boil. Strain, cool, and keep covered. 

(d) Apple Sauce: Take 6 apples and peel, core, and 
cut them into quarters. Place them in an enameled dish ; 
sprinkle over them 1 tablespoonful of sugar; add 1 cup 
of cold water; put the dish on the stove, and boil the 
apples to a mush (about thirty minutes). 

(e) Orange Gelatin: Soak y 2 box of shredded gelatin 
in cold water for thirty minutes. Add 2 cupfuls of boil- 
ing water, and dissolve. Then add 1 cupful of sugar, 
the juice of 1 lemon, and a cupful of orange juice. 
Strain through a fine strainer (or a cloth) into moulds, 
and set away to harden. 

Eggs. 

Use only soft-boiled or poached eggs. Be sure that 
the eggs are fresh. Drop egg in boiling water; imme- 
diately turn flame out, and allow to stand for five 
minutes. 

Casein Gruel. 

To make 10 ounces — each ounce equals 18 calories: 
Casein, 6 level tablespoonf uls ; flour ball, 2 level table- 
spoonfuls ; water, 6 ounces ; milk, 8 ounces. 

Mix casein and flour ball together with the water — 
let boil three minutes directly over the flame, stirring 
constantly. Add the milk gradually and bring again to 
boil. Place in double boiler and cook three to four hours, 
stirring occasionally. Strain. 



■APPENDIX. 443 

Thick Cereal (Sauer). 1 

Skimmed milk, 9 ounces; water, 12 ounces; farina, 
6 tablespoonf uls ; Dextri-Maltose, 3 tablespoonfuls. 

Boil for one hour in a covered double boiler. Sugar 
and salt may be added. 

Pap. 

Put 1 pint of milk on to boil ; add butter the size of a 
walnut. Beat 1 egg thoroughly. When milk boils, add 
the beaten egg, stirring constantly. Mix V/z tablespoon- 
fuls flour into a paste and add to mixture, stirring con- 
stantly. Allow mixture to boil ten minutes. Just before 
taking from the fire add a pinch of salt. May be taken 
plain, or with milk and sugar as directed. 

Cornstarch Pudding. 

Take 1 pint of milk and mix with 2 tablespoonfuls of 
•cornstarch; cane-sugar, 1 tablespoonf ul. Flavor to 
taste; then boil the whole eight minutes. Allow to cool 
in a mould. 

Custard Pudding. 

Break 1 egg into a teacup and mix thoroughly with 
sugar to taste. Then add milk to nearly fill the cup. 
Mix again, and tie over the cup a small piece of linen. 
Place the cup in a shallow saucepan half full of water, 
and boil for ten minutes. 

If it is desired to make a light batter pudding, a tea- 
spoonful of flour should be mixed in with the milk be- 
fore tying up the cup. 

Infant's Gelatin Food. 

About 1 teaspoonful of gelatin should be dissolved by 
boiling in J / 2 pint of water. Toward the end of the boil- 



1 L. W. Sauer : Thick cereal in the treatment of pyloric steno- 
sis. Arch, of Ped. xxxv, 385, 1918. 



444 INFANT FEEDING. 

ing, % pint of cow's milk and 1 teaspoonful of arrow- 
root (made into a paste with cold water) are to be 
stirred into the solution, and 1 to 2 tablespoonfuls of 
cream added, just at the termination of the cooking. It 
is then to be moderately sweetened with white sugar, 
when it is ready for use. The whole preparation should 
occupy about fifteen minutes. 

Albumin or Eiweiss Milk (Finkelstein). 

One quart. Take fresh whole milk, bring to a tem- 
perature of 98° to 100° F. Then add 2 level tablespoon- 
fuls of chymogen powder to a quart of milk; place in a 
water bath of 107° F., for fifteen to twenty minutes, 
until coagulated. Then hang in a sterile muslin bag for 
one hour to drain. 

To the curd of 1 quart of milk add 1 pint of buttermilk, 
and rub through a copper gauze strainer three times. 
Then add 2 level tablespoonfuls of wheat flour, flour 
ball, or Imperial Granum, rubbed to a paste with 1 pint 
of water. Boil ten minutes, cutting back and forth con- 
stantly, not stirring, with a large wooden spoon, other- 
wise large curds will form. If needed, water should 
again be added, to make the finished mixture one quart. 
Finkelstein advises the early addition of 3 per cent, of 
carbohydrate in the form of a maltose-dextrin compound. 
This is best done by dissolving the sugar in a moderate 
quantity of water, and adding while the mixture is being 
boiled. It must not be heated above 100° F. before feed- 
ing, otherwise it will clump. 

Albumin milk contains : protein, 3 per cent. ; fat, 2.5 
per cent.; milk-sugar, 1.5 per cent.; starch, 1.0 per cent.; 
salts, 0.5 per cent. Caloric value is 450 calories per liter, 
or 12 calories per ounce. 

Indications for albumin milk (Finkelstein) : 

1. Diarrheas and all cases of abnormal intestinal fer- 
mentation (sugar). 



APPENDIX. 445 

2. Fat indigestion with low sugar tolerance. 

3. Gastro-intestinal infections associated with fre- 

quent stools. 

4. Systemic infections with intestinal complications. 

Albumin Milk (Miiller and Schloss). 

Use 1 quart of water and 1 quart of buttermilk, and 
boil for three minutes. Set aside for thirty minutes, and 
then pour off the upper 36 ounces of the whey. Boil the 
upper 4.5 ounces of a quart of fresh milk for three min- 
utes. Add 1 ounce of dextri-maltose to the boiled top 




Fig. 28. — Utensils needed for artificial feeding: Double 
boiler (small), pan, funnel, bottle-brush, 250-mil (8 oz.) 
graduated glass or pitcher, 6 nursing bottles and rack, 
paper caps for bottles (sterile), nipples, milk, sugar, flour, 
milk of magnesia, citrate of soda, tablespoon, dairy ther- 
mometer, vegetable mill. 

milk, and to this add the curds from the first mixture, 
which would equal 27.5 ounces, making 1 quart of the 
milk mixture. 

Larosan Milk. 

Two-thirds of an ounce of Larosan powder (p. 
428) is added to 3% pint of milk, and mixed thoroughly. 
Another whole pint of milk is heated to the boiling point. 
When it has come to a boil, it is added to the Larosan 
milk mixture, and the whole is placed on the flame and 
allowed to boil for five minutes. This may be diluted 



446 INFANT FEEDING. 

with water in the proportion of one-half Larosan milk 
and one-half water, or two-thirds Larosan milk and one- 
third water. 

This mixture, because of its high protein content and 
comparative ease of preparation, can be used as a substi- 
tute for albumin milk in the home. 

Butter and Flour Mixture of Czerny and 
Kleinschmidt. 1 

The Butter-flour feeding which is recommended by 
Czerny and Kleinschmidt represents a utilization of the 
fat of the cow's milk. It is claimed that the mixture 
is well tolerated, even by very young and underweight 
infants. 

For the preparation of this feeding, for every 100 Gm. 
of the diluting fluid. 7 Gm. of butter, 7 Gm. of wheat 
flour and 5 Gm. of cooking sugar are used. The butter 
is heated above a small flame, with good agitation with 
a wooden spoon until it begins to foam and all odor of 
fatty acids has disappeared. Then the wheat flour is 
added and mixed with the melted butter. Both of these 
are then cooked over a moderate fire (asbestos plate), 
with constant mixing until the mass becomes thin and 
somewhat brownish. Then 100 Gm. of warm water and 
5 Gm. of sugar are added and the entire mixture is again 
boiled, strained through a hair sieve and finally added to 
the boiled and afterwards cooled milk. The mixture 
ready for feeding must be kept cool, but it is not neces- 
sary to sterilize it again. The amount to be added to 
milk mixtures in infants below 3000 Gm. should be one- 
third ; in those of about 3000 Gm. and above, about two- 
fifths of the final mixture. It should be administered 
in quantities of not more than 200 Gm. per kilo body 
weight in a day. 



i Jahrbuch f. Kinderh. 87. 1918. 



APPENDIX. 447 

Meats. 

Raw or slightly cooked beef, scraped and seasoned, 
can be fed in amounts equaling a tablespoonful at 
eighteen months or sooner, once daily. 

Take meat, preferably from the round, free from fat. 
Place on a board and scrape with a silver spoon. When 
you have the desired amount of meat pulp, shape into a 
pat and broil on a hot, dry spider. Do not cook too long. 
When done, season with a little salt and butter. Serve. 
A few drops of lemon juice may be added. 

Later, lamb, beefsteak, roast beef and chops are the 
best, and should be broiled. By no means fry any meat 
for the baby. Soup meat, well cooked, may also be given. 
All meats should be very finely cut before giving them 
to children. 

BOTTLES AND NIPPLES AND THEIR CARE. 

The nursing bottle should be of such a construction 
that every portion of it is easily reached with a proper 
brush. This necessitates the avoidance of sharp corners 
and angles, and makes the smooth stream lines in its 
construction desirable. It should be made of goOd glass, 
not easily broken, capable of being boiled repeatedly 
without cracking, and should hold about 8 to 10 ounces. 
Several nursing bottles should be kept on hand, and, if 
possible, as many bottles as there are nursings in a day 
should be available, so that the whole day's feeding may 
be prepared according to the particular formula, and the 
mixture then iced, and the individual bottles warmed on 
a water-bath whenever necessary. New bottles should 
be annealed by placing them in a vessel with cold water, 
and then bringing the water to a boil, boiling for twenty 
minutes, and then leaving the bottles in this water until 
it will cool off again. Bottles thus treated do not crack 
so easily when hot fluids are poured into them. After 
nursing, the bottle should immediately be rinsed with 



448 



INFANT FEEDING. 



cool water, and then washed with hot water and soap 
suds by means of a bottle brush. Afterwards the bottle 
should be set aside, inverted, so as to drain. Before use, 
the bottles should be boiled for five minutes. To avoid 
cracking, they must be placed in cold water and heated 
slowly. After the food has been prepared, the individual 
bottles may be filled and stoppered with sterile cotton, or, 
better, sterile paper caps, which are sold for this purpose. 




m m 



Fig. 29. — Good and bad nursing bottles. 1. Ordinary 
small-neck nursing bottle as sold in drug stores (8-ounce). 
2. Improved large-neck nursing bottle (made in 5- and 10- 
ounce size). 3. Hygiea nursing bottle. 

Nipples that can be turned inside out and easily 
cleansed should be selected. The conical shaped nipple is 
preferable. The hole in the nipple should be of such size 
that the milk will drop rapidly and not flow when the 
bottle is inverted. New nipples should be boiled before 
they are used. After using, every nipple should imme- 
diately be washed with soap and water, being turned in- 
side out, boiled and finally dropped into a sterile jar, 






APPENDIX. 



449 



where it is to be kept dry until ready for use again. 
Keeping the nipples dry lengthens the life of the rubber. 
Several nipples should always be kept on hand. 

CARE OF FOOD DURING TRAVELING. 

Whenever possible, the baby should be kept on its 
usual diet during the long journey. This is usually ac- 







'■'■■'■ N. 






! 

.■•■: 

1 


i 

H 


y ■'■'" ^^T^ 



Fig. 30.— A milk station consisting of three rooms. Room 
1. For all used bottles, bottle washers, and steam bottle 
sterilizers. Room 2. A clean room for preparation of for- 
mulas. This room also contains milk separator, fat-test- 
ing apparatus and butter churn. Room 3. Pasteurizing and 
sterilizing apparatus. 



complished without much difficulty when the baby is on 
boiled milk. If it has been fed on a raw milk mixture, 
the milk must be boiled before starting. When for any 
reason it is impractical to carry the milk mixture, evap- 
orated milk or powdered milk may he used. (See Pro- 
prietary Infant Foods, page 425.) In the use of evapor- 

20 



450 INFANT FEEDING. 

ated milk, a fresh can must be opened at least once daily. 
When it is known that the baby's formula is to be 
changed, it should be tried out on the new food before 
starting on the journey. As soon as possible, the pre- 
vious diet should be re-established. All water given to the 
baby while traveling must be boiled. The infant's food, 
after boiling for at least ten minutes, should either be 
placed in individual nursing bottles, or in bottles holding 
not more than 1 pint, so that not more than two or three 
feedings should be given from a single bottle. The 
bottle should be packed in ice, using care so that none of 
the ice reaches the top of the bottle. Upon reaching the 
train they should be placed in the ice-box of the dining 
or buffet car, unless a private ice-box is available. The 
baby's bottle can be warmed on the train by setting in a 
dipper of warm water, which may be carried hot in a 
thermos bottle, if the journey is to be a short one. Care 
must be taken that the water be not too hot, otherwise the 
cold bottles will be cracked. The nipples may be carried 
in a wide-mouthed, well-corked bottle, sufficient to cover 
the individual feedings. The nipples and bottles should 
be cleansed immediately after use. 

THE DIAPER. 

The diaper should be made of soft, light, and ab- 
sorbent material, such as cotton diaper cloth, which can 
be purchased for this purpose. Cotton-flannel is too little 
absorbent, and soon becomes hard as a result of washing. 
A second diaper may be folded into a square, and be 
laid under the hips to prevent the moisture from reach- 
ing the clothes, or instead of this arrangement, which is 
rather heating and bulky for summer use, a small diaper 
may be folded two or three times to form a square of 
about nine inches, and this may be placed inside of the 
larger diaper to receive the urine and feces. About four 
dozen diapers are needed for an average baby. 



APPENDIX. 451 

A rubber or waterproof cover should never be applied 
outside the diaper. It is very heating, and liable to pro- 
duce chafing and eczema. Diapers should be changed as 
soon as soiled, except at night, when they should be 
changed when the child is awakened for feeding, or 
when it is awakened by its own discomfort. Soiled 
diapers are always a source of discomfort, and not infre- 
quently the cause of severe irritation of the skin, as well 
as of infections of the genital and urinary tracts. This 
is especially true in the case of female infants. No diaper 
should be applied a second time without first being 
washed. All diapers which have been soiled by dis- 
charges from the bowel should have the bulk of the feces 
removed from the diaper, and should be immediately 
washed with soap not too alkaline in character, and later 
boiled for twenty minutes, and thoroughly rinsed, so that 
all alkali may be removed. They should then be aired 
thoroughly. Soda and washing-powders should be 
avoided because of the danger of irritating the child's 
buttocks after being moistened by the urine. 

The diapers of an infant ill with an intestinal infection 
should be cared for separately from those of other chil- 
dren. After changing the diapers, the nurse's hands and 
nails should be scrupulously cleansed with brush and file. 

BABY'S DAILY BATH. 

The baby should be bathed at least once a day, and on 
hot days even as many as three sponge-baths may be 
given. In the first six months the temperature of the 
bath should be 100° F., and in the second half of the 
year from 90° to 95° F. The room in which the bathing 
is done should have a temperature of at least 70°, and 
not more than 75° F. 

Toward the end of the first year the infant may be 
sprayed for 15 to 30 seconds with water at 75° to 80° F. 
This should be followed by brisk rubbing of the entire 



452 



INFANT FEEDING. 



body. In young infants the bath is most conveniently 
given before the mid-morning feeding, and the face and 
hands may be sponged before the 6 o'clock feeding. In 
older infants, a cool sponge and massage may be given in 
the morning, and the warm bath at bedtime. 

Before the umbilical cord has separated, sponge-bath 
only should be given, and never a submersion bath, for 




Fig. 31. — Hospital bathroom. Located between two small 
wards for infants, showing two metal water jackets rest- 
ing on a porcelain sink. These can be filled with water, and 
have a registering thermometer for indicating the tempera- 
ture before giving the bath. They are covered with a clean 
towel for each baby. Baby is showered from an automatic 
mixing tank, which registers temperature of the water in 
the tank. The room further contains a scale and a low 
dressing table, with the various dressings, powders and 
ointments to be used. Also low nursery chairs, collapsible 
bags for soiled linen, and waste basins. 



the fear of infection of the umbilical stump. Sponge- 
bath may be given on a towel, and when a tub-bath is 



APPENDIX. 453 

given, the child should be allowed to rest upon the at- 
tendant's left arm, which is slipped under its back from 
the baby's right side. By grasping the baby under the 
armpit with the left hand a good hold is secured, which 
prevents slipping. The right hand is left free for wash- 
ing the baby. A special wash-cloth, preferably of cheese- 
cloth, should be provided for washing the baby's face and 
head. 

A pure, bland, white soap should be used. Very little 
soap is needed for cleansing the baby's skin, and it is 
most important that the skin should be thoroughly rinsed. 
If the skin is sensitive and easily irritated, soap should be 
avoided, and the bran-bath (made by putting a handful 
of bran in cheese-cloth bag and soaking this in the water 
until milky) should be used. 

After the bath the baby should be wrapped in a large 
soft towel and dried by sponging, and not by rubbing. 
Special attention should be paid to folds and creases of 
the skin, and these should be well powdered after being 
thoroughly dried. 

Only warm baths should be used in infants who be- 
come pale and cyanotic when a cooler bath is used. 

Care should be taken in bathing all children suffering 
from coughs. Great care should also be used while bath- 
ing a child suffering from vulvovaginitis, to avoid infec- 
tion of the eyes. 

COLD BATH AND COLD PACK. 

Cold bath is an efficient antipyretic and nervous de- 
pressant in cerebral irritation, but it is a somewhat severe 
procedure for the infant, and is less frequently indicated 
than in the adult. It is to be used only in infants who 
react well. The bath is started with water at 100° F., 
and the temperature is then gradually lowered by the 
addition of ice-water, down to about 80° F. The infant 
should be continually rubbed while in the bath. The 



454 INFANT FEEDING. 

bath should not be longer than five to ten minutes, and 
should be discontinued at once, if any cyanosis appears. 
The infant must be dried quickly, and then wrapped in a 
dry blanket, without dressing, and put to bed. 

In most cases, however, a cold pack- is preferable to 
cold bath, especially in young infants, as the former is a 
somewhat milder procedure. Cold pack is one of the best 
antipyretic procedures in infancy and childhood. The 
naked child is wrapped in a blanket wrung out of water 
at a temperature of about 100° F., and is then rubbed 
with ice through the blanket for about five to ten min- 
utes. Ice-bag to head and hot-water-bag to feet are very 
useful — often necessary. After rubbing with ice, the 
child is left in the blanket, and covered well. The blanket 
may be removed, the child dried; and put into a dry 
blanket after about one hour. 

HOT BATH. 

Hot bath is indicated in cases of collapse or shock as a 
stimulating procedure; and prolonged hot bath as a dia- 
phoretic procedure: It should, be started with water at 
a temperature of 100° F., and the temperature gradually 
raised to about 105° F. by addition of hot water. An 
ice-cap or cold cloth should be applied to the head. A 
thermometer should always be used while giving a hot 
bath. The infant should be well rubbed during the bath, 
which should be continued for about ten minutes. After 
the hot bath the infant should be well dried, until the 
skin is red, and then wrapped in a blanket and put to bed. 

MUSTARD BATH AND MUSTARD PACK. 

Mustard bath and mustard pack are indicated for their 
stimulating effect in cases of shock, or collapse, and in 
acute congestion of internal organs, and also in con- 
vulsions. 

The amount of mustard used and the temperature of 
water is the same in both procedures. Powdered mus- 



APPENDIX. 455 

tard, in quantity of about 1 level tablespoonful to each 
gallon, or 1 teaspoonful to each quart, when smaller 
quantities are sufficient, should be used. Full quantity 
of mustard powder is first dissolved in about a gallon of 
warm water; and to this the rest of the water is added, 
while preparing the bath. For giving- the pack, a smaller 
quantity of water is usually required. The. temperature 
of the water should be about 100° F., and it may be 
raised to about 105° F. by addition of . hot' water. Cold 
applications should be made to the head. 

The bath should be continued for *about ten minutes, 
accompanied by rubbing the skin, and followed by ablu- 
tion with lukewarm water, rapid drying, wrapping in a 
blanket, and rest. 

Mustard pack is somewhat less efficient than mustard 
bath, but it is also less severe and less disturbing to the 
infant. The naked child is wrapped in a blanket which 
has been wrung out of water prepared as above stated. 
The infant is left in the pack until the skin is well red- 
dened—about ten to twenty minutes — then washed off 
with warm water, followed by lukewarm water ablution, 
dried, and put to bed without dressing. 

STOMACH WASHING. 

The apparatus for stomach washing consists of a soft 
rubber catheter, 20 to 24 French, or infant stomach-tube, 
a small funnel, 'attached to a rubber tube, and a glass 
connection between the catheter and the tube. 

The infant is wrapped with the arms confined, and is 
held in the sitting position, with a large basin at the 
nurse's feet. The tongue is depressed with the forefinger 
of the left hand, and the right hand passes a catheter 
rapidly backwards into the pharynx and down into the 
esophagus. Gagging is aggravated by passing this 
catheter slowly. After the catheter is part way in the 
esophagus, it should be passed more slowly. As the 



456 INFANT FEEDING. 

cardiac orifice is passed, and the catheter enters the stom- 
ach, gagging again becomes more evident. This can be 
used as a sign that the catheter is entering the stomach. 
A good rule to follow in passage of the catheter is to 
measure the distance from the root of the nose to the 
tip of the ensiform cartilage, which approximates the 
distance from the teeth to the cardiac end of the stom- 
ach, and then pass the catheter about an inch farther. 
The passage into the stomach is usually marked by the 
appearance of curdled milk in the glass connecting tube. 
The funnel should now be raised as high as possible, to 
facilitate the escape of any gases from the stomach, and 
should then be lowered, in order to siphon any fluid con- 
tents. The funnel is then raised, and warm water at a 
temperature of about 100° F. is poured into the stomach 
quickly. The amount of water passed into the stomach 
at any time should about equal the quantity of the feed- 
ing to which the child is accustomed. The funnel is then 
lowered, just before all of the water leaves the tube, and 
the water siphoned out. This procedure is repeated a 
number of times, until the fluid comes back clear. Dur- 
ing withdrawal, the tube must be compressed carefully to 
prevent leakage into the larynx. The washings should 
be collected and measured, so that the quantity remaining 
in the stomach may be estimated. 

Sterile water or one-half strength normal saline, 
Ringer's solution, or a solution containing sodium chlo- 
ride 5 Gm., sodium bicarbonate 5 Gm., and water 100 
mils, may be used. It is frequently advisable to allow 
part of the solution to remain in the stomach. 

Stomach washing is indicated in vomiting due to pylo- 
rospasm, hypertrophic pyloric stenosis, all forms of gas- 
tric irritation, chronic indigestion, acute dilatation of the 
stomach, and food and drug poisoning. 



APPENDIX. 457 

CATHETER FEEDING BY MOUTH. 

The same apparatus is used as in stomach washing, 
the same technic being used for the introduction of the 
catheter, except that its tip should not be made to pass 
the cardiac end of the stomach, the food being allowed 
to enter the esophagus just above the cardia. This is 
accomplished by passing the catheter about one-half inch 
less than the distance from the root of the nose to the 
tip of the ensiform cartilage. The infant should be lying 
on its back, and not in sitting posture, as recommended 
in stomach washing. When the feeding is finished, the 
catheter should be tightly pinched between fingers and 
rapidly withdrawn, to prevent any food from trickling 
into the larynx. It is often advisable to wash the stom- 
ach before the food is introduced. (See Fig. 7, page 
89.) 

Catheter feeding is indicated in the feeding of pre- 
mature infants, infants refusing their diet, those too 
weak to nurse, in the presence of persistent vomiting, and 
in all cases of delirium and coma. 

CATHETER FEEDING BY NOSE. 

This is not indicated in young infants. In older chil- 
dren it is often impossible to pass the catheter through 
the mouth, without undue struggling. It is also indicated 
in throat paralysis following poliomyelitis and diphtheria, 
and after throat operations and intubation. The method 
is similar to that described in catheter feeding by mouth, 
except that a smaller catheter (No. 15 French) is to 
be used. 

IRRIGATION OF THE COLON AND 
RECTAL FEEDING. 

The apparatus varies somewhat with the purpose to be 
accomplished. Where large quantities of fluids are to 
be introduced, it is necessary to use a douche-can or 



458 INFANT FEEDING. 

fountain syringe, 4 to 5 feet of tubing, and a flexible 
rectal tube or soft rubber catheter (size 20 to 24 French). 
When small quantities are to be introduced, a glass fun- 
nel may be used in place of the douche-can. When large 
quantities of fluid are used, the can must not be raised 
more than 2 feet above the child's body. The child 
should be turned upon its side, with the lower limb ex- 
tended, and the upper thigh flexed upon the abdomen. 
The catheter should be well oiled, and introduced for 
about 3 to 4 inches when large quantities are to be given, 
and further introduction of the catheter may be made 
while the solution is flowing into the rectum. For most 
purposes the solution should be about 100° F. 

Indications. 1. To produce evacuation of the bowel. 
A salt solution containing a level teaspoonful of salt to 
a pint of tepid water or weak soap-suds solution, or a 
teaspoonful of glycerin in an ounce of water; or in the 
presence of large fecal masses, 2 or 3 ounces of sweet 
oil may be used. 

2. To reduce temperature. At least 1 to 4 quarts of a 
salt solution or weak soap-suds enema at about 95° F. 
should be used, allowing about Yz to 1 pint to enter the 
rectum, and repeating after expulsion. 

3. Rectal feeding. A normal salt solution or nutrient 
enemata containing 2 level tablespoonfuls of dextrose to 
the pint of normal saline solution may be used. It is 
indicated in cases of acidosis, and also in the presence of 
vomiting, intoxication, and decomposition where the body 
is in need of water. It is usually necessary that only a 
small amount (2 to 6 oz.) of this solution be introduced 
at a time, or that it be given by the drop method. Other- 
wise it will not be retained. It should be repeated at 
regular intervals of from two to four hours. It may be 
necessary to compress the buttocks for twenty minutes 
after administration, when the fluid is not well retained 
otherwise. 



APPENDIX. 459 

4. Medication. There are two indications for rectal 
medication : ( 1 ) For the systemic effect. The drugs 
most commonly used for this purpose are chloral hydrate 
and the bromides, more especially in the presence of 
convulsions or coma. They should be diluted in small 
quantities of water or salt solution, not over 1 ounce, and 
may be administered in about four times the oral dose 
for the given age. (2) For local effect. Enemata 
are indicated for their local effect in the presence of 
marked tenesmus, inflammation, ulceration and hemor- 
rhage. Not infrequently the tincture of opium (3 to 5 
drops) and tincture of belladonna (3 to 5 drops) are 
administered, probably best in a 10 per cent, starch solu- 
tion, for their sedative effect. In the presence of in- 
flammatory processes, 1 per cent, silver nitrate solution 
may be used. 

SALINE SOLUTIONS. 

Solutions administered subcutaneously and intraven- 
ously should be maintained at a temperature approxi- 
mating 100° F. 

1. For subcutaneous use. They are especially indi- 
cated in the presence of considerable loss of body fluids 
through vomiting, refusal of diet, and diarrhea, and in 
the presence of acidosis. Rectal administration should 
first be tried, and, in case that sufficient fluids cannot be 
administered to meet the infant's needs in this way, hypo- 
dermoclysis should be instituted. In infants 2 to 4 
ounces can usually be administered, and in older children 
4 to 6 ounces. This can be repeated every four hours, 
if necessary, or until fluids can be supplied by another 
route. Fluids can be administered beneath the skin of 
the abdomen, chest, or lumbar region. There is some 
shock accompanying the administration of large quanti- 
ties of fluids subcutaneously, probably due to the pain, 
and it is frequently necessary to give a child in collapse 
some subcutaneous stimulation of camphor in oil (10 per 



460 INFANT FEEDING. 

cent. 1 mil), or adrenalin solution (1:1000, about 5 
drops), before administration. The stimulating injection 
is to be made in regions of the body other than where the 
saline injection is made. 

The best solutions for this purpose are 

(a) NaCl 7.5 grams. 

KC1 0.1 

CaCl 0.2 " 

Water q. s. ad 1000.0 mils. 

(b) Dextrose may be added to the above solution in 

proportion of 50 grams to the liter (5 per cent.). 

All solutions used for subcutaneous administration 
should, if possible, be made from fresh distilled water, 
and re-sterilized shortly before use. 

2. Intravenous injections. The same solutions as in- 
dicated for subcutaneous use may be administered intra- 
venously. Sodium bicarbonate, 30 Gm. to the liter, being 
added in the presence of acidosis and dextrose, 50 Gm. 
to the liter in cases of malnutrition and decomposition. 
Either direct or indirect transfusions of blood are also 
of extreme value in the presence of marked marasmus. 

Tcchnic. In older infants and children the injection 
may be made into the external jugular or median basilic 
or median cephalic veins. In young infants with open 
fontanelle, the longitudinal sinus is the most convenient 
point for administration. However, in the use of the 
latter method extreme care must be used, because of the 
ease with which the sinus wall can be punctured. All 
apparatus used in the intravenous administration must 
be thoroughly and freshly sterilized before use. "Where 
a moderate quantity of fluid is to be administered (2 mils, 
10 mils, or 20 mils) all-glass Record or Luer syringes can 
be used. In injection of fluids into the longitudinal sinus 
a short bevelled needle, about 0.75 inch in length, should 
be introduced at the posterior angle of the fontanelle. 

The region of the fontanelle is sterilized, and the first 
syringe is three-quarters filled with the fluid to be in- 



APPENDIX. 461 

jected. The syringe is now connected with a needle by 
means of a short piece of rubber tubing to allow flexibil- 
ity in case of movements on the part of the child, and the 
needle is passed into the sinus, its entrance being recog- 
nized by a sudden lessening of the resistance. Helmholz 1 
suggests that the question of negative pressure within the 
sinus is one that must not be overlooked, and it is always 
well in entering the sinus to have the syringe attached, 
and before injection to withdraw blood, to make sure that 
the needle is in the sinus. Unless a head-clamp, as 
described by Helmholz is available, two assistants are 
required, one to hold the child's head firmly, and the 
second to manage the syringe, while the physician steadies 
the needle. From 100 to 200 mils of either a saline, dex- 
trose solution or citrated or fresh blood can usually be 
administered without difficulty. Unger 2 has described an 
apparatus whereby large quantities of fresh blood can be 
transfused. 

HOME-MADE ICE-BOX. 

The following home-made ice-box described by A. F. 
Hess will answer, if a more elaborate refrigerator is 
not available. 

Get from your grocer a deep box about 18 inches 
square, and put 3 inches of sawdust in the bottom. Place 
two pails in this box — one a smaller pail, inside the other 
— and fill the space between the outer pail and the box 
with sawdust. The nursing bottles filled with milk are 
placed in the inner pail. This pail is then filled with 
cracked ice, which surrounds the bottles. The inner pail 
should have a tin cover. Nail several thicknesses of 



1 I telmholz, II. F. : The longitudinal sinus as the place of 
preference in infancy for intravenous aspirations and injections, 
including transfusion. Am. Jour. Dis. Child., x, 194, 1915. 

2 Unger, J. J.: A new method of syringe transfusion. Jour. 
Am. Med. Ass'n, lxiv, 582, 1915. 



462 



INFANT FEEDING. 



newspaper on the under surface of the cover of the box. 
This ice-box should be kept covered, and in a shady, cool 
place. The water from melted ice should be poured off. 
and the ice renewed at least once each day. 




Fig. 32. — Bed complete, with removable metal lid and 
collapsible hood in place. The hood and lid can be re- 
moved as indicated. 



ELECTRIC-HEATED WATER-JACKETED 
INFANT BED. 

This special bed, designed by the author is for use in 
the care of premature and poorly nourished infants. The 
advantages of this apparatus are : 

1. Safety. The maximum temperature to which the 
water can be warmed with the electric heater is about 



APPENDIX. 



463 



155° F., with a room temperature of 70° F. and rheostat 
on contact 6, this giving a maximum temperature within 
the bed of about 110° F., with the lid and hood on. 

2. Economy of operation, and, most important, the 
elimination of a trained attendant. 




Fig. 33. — 4, copper wall covering asbestos layer ; 9, stand 
supporting bed; 11, 14, inner and outer walls of copper 
water jacket; 12, asbestos layer insulating water jacket. 
15, water within jacket surrounding sides and floor of 
bed ; 18, water gauge ; 19, plug in opening used for filling 
jacket ; 20, cock for emptying jacket ; 22, removable crib ; 
24, air space underneath crib ; 26, heating plate ; 28, rheo- 
stat ; 29, electric plug. 

3. Simplicity of operation. It needs practically no 
attention unless there are extreme ranges of temperature 



464 



INFANT FEEDING. 



in the ward, since the asbestos insulation prevents 
radiation from the outer surface of the bed, and the 
heater holds the water at a constant temperature. It is 
seldom necessary to change the rheostat more than 
twice daily. 

4. Ease of control of ventilation within the bed in 
the general wards of the hospital. 

5. Humidity, which is little lower than that of sur- 
rounding air. 

A COPPER JACKET TO PROTECT HEATING PADS. 




Fig. 34. — An asbesto -lined copper receptacle for electric 
heating pads for use in the care of premature and debili- 
tated infants (Hess). To avoid the danger of fire from 
short circuits in electric heating pads, a copper receptacle 
is used, 16 inches long, 13 inches wide, and 1% inches high, 
into which a 12 x 15-inch heating pad is laid. To allow of 
a maximum radiation from the lid or upper surface of the 
same, the floor and sides are lined with asbestos sheeting, 
while the lid is not lined. The cord passes through a small 
rubber insulator at the side to prevent contact with the 
metal and injury to the cord. This simple device can be 
used temporarily in wards and homes where better facili- 
ties for the care of this class of infants are lacking. It is 
to be placed in the bottom of a basket or crib, under the 
mattress or pillow. 



APPENDIX. 465 

CASE HISTORY. 

(A) Present Illness. 

1. Complaints: Mother's or patient's own statement. 

2. Get history of present illness in detail : Onset, course 

and duration. Fever. Vomiting. Stools. Urine. 
Eruptions. Sleep, etc. 

3. Previous treatment, if any. 

(B) Previous History. 

1. Birth: Para, nature and complications. 

2. Development: Teeth (time of eruption), sat erect, 

walked, talked, mentality. 

3. General Health : Robust or delicate, appetite, colds, 

fevers, coughs, bowels, convulsions, mouth- 
breathing, running ears, bed-wetting, etc. 

4. Illnesses: Diseases similar to the present. Kind, 

date, duration, severity, recurrences, complica- 
tions, careful history of acute infectious diseases. 

5. Feeding: In detail in every infant. 

(a) Breast feeding: How long, intervals, condition 

of the baby, why discontinued. 

(b) Artificial feeding: Kind of food, intervals, how 

prepared, how much at each feeding, total 
quantity, how long used, effect on baby and 
on bowels, why discontinued. 

(C) Family History. 
Parents, brothers and sisters. 

(Constitutional diseases: Tuberculosis, syphilis, mis- 
carriages (order of), rheumatism, nervousness or insan- 
ity, alcoholism.) 

(D) Examination. 
Examine patient fully. 

1. General appearance and zveight: Nutrition and gen- 

eral development, facial expression (intelligence, 
pain, etc.), amount of prostration, pallor, cry, 
nervous condition, posture, respiration. 

2. Skin : Eruptions, turgor. 

30 



466 INFANT FEEDING. 

3. Temperature : Pulse and respiration (in infant 

omit temperature until 11). 

4. Head: Size, shape, fontanelles (size, tension), 

cranio-tabes, eyes, nose (mouth, tongue, teeth 
under 12). 

5. Neck : Goiter, glands, rigidity. 

6. Chest: Shape, deformities, inequalities, expansions, 

lungs and heart in detail. 

7. Abdomen: Size, distention, retraction, tenderness, 

rigidity, liver, spleen, bladder, kidney, fluid and 
tumors. 

8. Spine : Deformities, rigidity. 

9. Genitalia and genital region : Phimosis, vaginal dis- 

charge, fissures, inflammation, eruptions, hemor- 
rhoids, pin-worms, etc. 

10. Extremities: Glands, deformities, paralyses, at- 

rophy, muscle tone, reflexes, athetosis, swell- 
ing, tenderness, discoloration, joints, gait. 

11. Temperature : In child»under 3 years always rectal, 

and often in older children. 
12. Mouth: Teeth, tongue, stomatitis, exanthemata, 
pharynx, tonsils, adenoids. 

13. Middle ear. 

14. Special examinations: Urine, blood, sputum, cul- 

tures, feces, vaccinations, serum reactions, etc. 

AVERAGE WEIGHTS. 

Boys Girls 
Age Pounds Pounds 

Birth 7.55 7.16 

Six months 16.50 15.50 

Twelve months 20.50 19.80 

Eighteen months 22.80 22.00 

Two years 26.50 25.50 

Three years 31.20 30.00 

Four years 35.00 34.00 

Five years 41.20 39.80 

Six years 45.10 43.80 

Seven years 49.50 48.00 



APPENDIX. 467 

Average Weights — Continued. 

Boys Girls 

Age Pounds Pounds 

Eight years '. . . . 54.50 52.90 

Nine years 60.00 57.50 

Ten years 66.60 64.10 

Eleven years 72.40 70.30 

Twelve years 79.80 81.40 

Thirteen years 88.30 91.20 

Fourteen years 99.30 100.30 

Fifteen years 110.80. 108.40 

Sixteen years 123.70 113.00 

MEASUREMENTS. 

Age Height 

in. 

Birth 20.5 

6 months 25.0 

1 year 29.0 

2 years 32.5 

5 years 41.5 

Head at birth, 13.75 inches. First year, gain 4 inches; 
second year, gain 1 inch; 2 to 5 years, gain 1.5 inches for 
the 3 years. 

Large head and small chest suggests rickets. The head 
is larger than the chest until second year, normally. 

GENERAL DEVELOPMENT. 

A healthy infant speaks single words toward the end 
of the first year, uses short sentences at the end of the 
second year ; sits erect at the seventh month ; stands with 
assistance at ninth or tenth month; attempts to walk at 
twelfth or thirteenth month, and walks freely at the 
fourteenth or fifteenth month. 



SLEEP. 

The healthy newborn infant sleeps practically all the 
time except when being fed. 



Chest 
in. 

13.25 


Head 

in. 

13.75 


16.0 


17.0 


18.0 


18.0 


19.0 


18.75 


21.0 


20.5 



468 INFANT FEEDING. 

Hours 
per day 

At birth 20 to 22 

At end of 1st year 16 " 18 

During 2d and 3d years 12 '' 13 

During 4th and 5th years 10 ' 11 

During 12th and 13th years 8 '" 9 



ORDER AND AVERAGE TIME OF ERUPTION 
OF THE TWENTY DECIDUOUS TEETH. 

Months 

2 lower central incisors 6 to 9 

4 upper incisors 8 " 12 . 

2 lower lateral incisors and 4 anterior 

molars 12 " 15 

4 canines 18 " 24 

4 posterior molars 24 " 30 

At 1 year should have 6 teeth. 

At 1 year 6 months should have 12 teeth. 

At 2 years should have 16 teeth. 

At 2 years and 6 months should have 20 teeth. 



PERMANENT TEETH. 

Years 

1st molars 6 

Incisors 7 to 8 

Bicuspids 9 " 10 

Canines 12 " 14 

Second molars 12 " 15 

Third molars 17 " 25 



CLOSURE OF FONTANELS. 

Posterior fontanel usually closes by the end of the 
second month. Anterior fontanel at the end of the first 
year is about 1 inch in diameter, and usually closes at the 
eighteenth month. Normal variations, from fourteen to 
twenty-two months. 



APPENDIX. 



469 



AVERAGE DAILY QUANTITY OF URINE 
IN HEALTH. 

Ounces 

1st 24 hours to 2 

2d 24 hours % " 3 

3 to 6 days 3 " 8 

7 days to 2 months 5 " 13 

2 to 6 months 7 " 16 

6 months to 2 years 8 " 20 

2 to 5 years 16 " 26 

5 to 8 years 20 " 40 

8 to 18 years 32 " 48 

AVERAGE RATE OF PULSE AND 
RESPIRATION. 

Pulse Respirations 

Birth 140 35 to 40 

1 month 120 25 " 40 

6 to 12 months 105 to 115 25 " 30 

2 to 6 years 90 " 105 25 

7 to 10 years 80 " 90 22 " 25 

11 to 14 years 75 " 80 • 20 



BLOOD-PICTURE IN HEALTHY CHILDREN. 



Newborn 
Hemoglobin 110 percent. 
Erythrocytes 5 to 8 millions 



Infants 
70 to 95 per cent. 
4.5 to 5.5 millions 



Older children 

65 to 95 per cent. 
4 to 4.5 millions. 



AVERAGE WHITE CELL COUNTS. 

1. Healthy children between 1 and 15 years of age 
average between 7000 and 15,000 leucocytes, approxi- 
mately the same as adults. 

2. Polymorphonuclear neutrophils increase gradually 
from 30 per cent, in the first year to about 70 per cent, 
in the fifteenth year. 

3. Lymphocytes decrease from 60 per cent, in the first 
year to about 30 per cent, in the fifteenth year. (This 
represents combined (large and small) lymphocytes.) 



4/0 INFANT FEEDING. 

4. The reversal of the percentages of neutrophils and 
lymphocytes occurs usually about the sixth year. 

5. Eosinophils average between 4 to 6 per cent., but 
vary greatly in different children at the same ages. 

6. Transitional cells average approximately 2 to 3 per 
cent., not varying greatly at the different ages. 

7. Mast-cells, about 0.3 to 0.6 per cent. Frequently 
absent. 

8. Large mononuclear neutrophils, 1 to 3.3 per cent. 
About the same at different ages. 

Stool symbols Urine symbols 

N = normal. A = albumin. 

S = soft. S = sugar. 

W = watery. Ac = acetone. 

F = fat-soap. D = diazo. 

M = mucus. I = indican. 

Bl = blood. C = casts. 

C = curds. P = pus. 

G = green. Bl = blood. 

Ep = epithelium. 

GRAPHIC RECORD SHEET. 

A brief description of the clinical sheet used in our 
wards may be of value, as it answers both the needs 
of a history sheet and of a daily chart as well. The 
points illustrated by it are: A graphic relationship 
between the temperature, weight, quality, and quan- 
tity of food taken, and the end-results on the stools 
and urine. Also separate spaces are provided for 
complications which may influence the preceding 
under the heading of symptoms, together with spaces 
for treatment other than dietetic, energy value of 
foods, vomiting, blood examinations, tuberculin re- 
actions, etc. The small figures 1-10 are used to make 
an electrical reaction curve in cases showing a spas- 
mophilic diathesis. 



APPENDIX. 



471 











SARAH MORRIS HOSPITAL FOR CHILDREN 




< 


I'll 


I" 


I 


is 

o 


? p p 
o 3 ? ? ? 


1 f 1 ? 1 ? 1 f 


1 


? 




°2 1111111 


iiiiisi t 






«> <T3 SYMPTOMS 


MEDICATION 






nan..,™ 


















> Z 








3 
























; 
















j 








* 
















« 








? 
















t 


| J | 






2 


| |. 














E 










j " 
















i 








J 
















S 








* 
















[[ 


i 






u 














[f 






■ ? ,? ? 






t 


l 
















[I 








n 
















ff 


g 






s 














ft 


ffn 






f 1h 


















' E 








E 





472 



INFANT FEEDING. 



DEPARTMENT OF PEDIATRICS 

UNIVERSITY OF ILLINOIS • COLLEGE OF MEDICINE 



s 

z 




























Rao 




Diagnosis 






1 


D«,o, 



ar.d laier developments 



DEVELOPMENT: T"'h 



GENERAL HEALTH: 



APPENDIX. 473 



PREVIOUS ILLNESSES 



i ■ . ' ' . .!-■■; ■!■•■ 



Why dhi"inin\i'ii 



PHYSICAL EXAMINATION 



474 INFANT FEEDING. 



Tl- MPERATUKE P 

LABORATORY EXAMINATIONS 



TREATMENT 



APPENDIX. 



475 







SUBSEQUENT TREATMENT AND REMARKS , 


Dale 


W,i e ht 















































































































































476 



INFANT FEEDING. 



INFANT WELFARE CONFERENCE 



House Flat Front Rear Floor . 



Date of birth- 



Referred by - 

Clinician 

WHY IS INFANT BROUGHT TO THE CONFERENCE! (Mothers answe 



.Cross index. Yes No_ 



(Does she think it is normal?) 

HISTORY OF PRESENT ILLNESS (Onset, duration prog 



Father - 
Mother 



Duration Delivery 



Miscarriages 



Order of Pregnancies Months 



PERSONAL HISTORY 

Full-term Premature 

Condition at birtb 

Teeth: First at 

Talked: Simple words at 

Menial development 



aonths Birth Wgt.. 



-mos Sat erect at- 



-mos. Walked at. 



Shoil sentences- 



APPENDIX. 



477 



PAST ILLNESSES: 

Diarrhea Rickets Bronchitis 
Snuffles Spasmophilia Pneumonia 
Colds Convulsions Otitis 
Adenitis Tonsillitis Measles 


Mumps Pertussis 
Scarlet Fever Chicken Pox 
Influenza Eczema 
Diphtheria Enuresis 


Pyelitis 

Acidosis 
Syphilis 


Rheumatism 
Chorea . - 

Endocarditis 
Nephritis 










FEEDING H1STOEI: 

Breast £ed Bottle 


Mixed 








_minutes. Does the baby empty the 












Quality of BREASTS good, lair, poor; 
How long did you nurse the baby exclusively? — 
How long did you nurse the baby altogether? — 


NIPPLES good, bad, 
months. Part nursing 

months 


inverted. 


months. 




ARTIFICIAL FEEDING HISTOKY TO PRESENT TIME 












PRESENT FEEDING IF ON' BOTTLE 








MIXTURE: 














Sugar (kind) 

Other ingredients 


tablespoonful (level). 





Is the mixture fed raw. pasteurized or boiled? 
Other foods taken amount 



DoC3 the baby take all of the feedings? 

Foods refused , 

Food idiosyncrasies imllk, cereal, fruits, vegetables, meat:; and eggs) 

Does the baby vomit? How much 

Docs the baby have colic? When 

How many times a day do the bowels move (average). Well, sick 

Color Consistency Mucus Curds. 



478 



INFANT FEEDING. 



PHYSICAL EXAMINATION 



Temperature- 



-Pulse- 



INSPECTION: Bright Dull 

GENERAL CONDITION: Fat Thin 

SKIN: Normal Prickly Heat 

Tissue Turgor Urticaria 

MUSCLES: Biceps and Thighs Firm 



HEAD: Normal 

Cranio-tabes- 
EY'ES: Pupils equal 



. prornmrnt__ 



(Underline each word describing condition) 
ius Phlegmatic Apathetic 
Fair Pocjr 

Eczema Scabies Seborrhea 
Impetigo Pediculosis Nails 
Flabby 
Kontanclles . , . 



Distance 
Blepharitis 



NAKF.S: Clear 



s|M s|,s : 
MOUTH: 
TONGUE: 
THKOAT: 
TONSILS: 
GLANDS: 



Maxillary- 

Normal 

Normal 
Normal 
Normal 
Normal 



l)j ., barge 
_Frontul_ 



Open 
Moist 

Injected 

Filiated 



Ethmoid 

Herpes Stomatitis (I 

Dry Injected 

Membrane (type) 

Buried Cryptic 

Ant-cervical Post- 



Inflamed Operated Slumps- 
Epitroclear 1 



TEETH: No Good 

EARS: Normal Perforati 

NECK: Thyroid 

CHEST: Normal barre 
LUNGS: 



ed Approximation good poor. Alveolar abscesses- 
Discharge right left character 

Other findings 



Harrison's Groove 



HEART: Area of dullness- 
Apex 4th 



Regular Irregular 

s: NONE 

presystolic 



Soft 



systolic 
diastolic 



_cm to left of mid-sternal line 
-cm to right of mid-sternal line 

Gth space in mid-clavicular line 
-cm outside, inside, mid-clavicular line 
Sounds: clear impure 



ABDOMEN: 



Blood Pressun 
tympanitic 





LIVER: Palpable— 
SPLEEN: Palpable 


Enlarged 
Yes 


Boundaries ii 


a Mid 


. CI.I, 
















GENITALS: 
EXTREMITIES: 


Phimosis 
Deformity 


Circumcised 
Normal 
Acquired 




Undescended Testicle 
Abnormal 
Congenital 


Hydrocele 


Vaginitis 
Rickets 



FEET: Arches good 
SPINE: Normal 
REFLEXES: Patellar 

WEICHT: Present 

LENGTH: Present 

CIRCUMFERENCE: Head 



flat pronated Posture good poor Gait 

Rigid Curvature Round Shoulders 

Brudzin^ki Oppenheim Trousseau 

Babinski Chvostek 



-Normal for height- 
-Normal for weight- 



vertex- 



APPENDIX. 479 



LABORATORY AND SPECIAL EXAMINATIONS 
URINE: Color Sp. gr. Reaction 

Sugar Acetone Diacetic Acid 

Pus Blood • Casts 

SPECIAL NOSE, THROAT, EAR and SINUS: 



RADIOGRAM OF CHEST, DIGESTIVE TRACT, i 



Reaction: 
Throat Culture:" 

Von Pirquet: negative positive cm. areola 

Vaginal Smear 

Electrical Reactions: COC AOC Relation AOC to ACC 

Shick Test: 

Skin Test for Proteins. 
Stool Exam, for Parasites. 
Toxin Antitoxin: 

SUMMARY OF DEFECTS FOUND 

Underweight for height pounds per cent 

Carious Teeth No. alveolar, abscesses 

Mouth Breather Cryptic Tonsils 

Enlarged Cervical Glands 

Otitis: dry discharging R. 
OTHER PATHOLOGICAL FINDINGS 



Hygiene 

Social Scrv 



SOCLAL SERVICE REPORT 
Neighborhood Home 
Bath tub sonitorv conditions 
Mother's attitude Remarks 



480 



INFANT FEEDING. 



CHILD WELFARE ( ONFERENCE 



N«mi» 
















Telephone 


House 


Flat 


Front 


Rear Floor 





























WHY IS CHILD BROUGHT TO THE CONFERENCE! (Mothers answer). 



.Cross index. Yes_ 



(Does she think it is normal?) 

HISTORY OF PRESENT ILLNESS (Onset, duration progress): 



Living Dead Age Condition of Health Cause of Death 



Duration Delivery 



Order of Pregnancies Months 



PERSONAL HISTORY 

Full-term Premature at_ 

Condltion at birth 

Teeth: First at m 

Talked: Simple words at 

Mental development 



: at mos. Walked at_ 

Short sentences mos. 



APPENDIX. 



481 



PAST LtL!t 


ESSES: 








Diarrhea 


Rickets 


Bronchitis 


Mumps 


Pertussis 


Snuffles 


Spasmophilia 


Pneumonia 


Scarlet Fever 


Chicken Pox 


Colds 


Convulsions 


Otitis 


Influenza 


Eczema 


Adenitis 


Tonsillitis 


Measles 


Diphtheria 


Enuresis 



Pyelitis Rheumatism 

Scurvy Chorea 

Acidosis Endocarditis 

Syphilis Nephritis 



Important details and other diseases 



PHYSICAL EXAMINATION 



.Pulse- 



Dull 



Thin 



Temperature— 
INSPECTION: Bright 
GENERAL CONDITION: 

SKIN: 

Normal Prickly Heat 
Tissue Turgor Urticaria 
MUSCLES: Biceps and Thigl- Firm 
HEAD: Normal Bosses prominent 

Cranio-tabes 

ETES: Pupils equal Unequal 

Motions: Normal 



(Underline each word describing condition.) 
Phlegmatic Apathetic 

Fair Poor 



Impetigo 
Flabby 
Fontan'elles 



NARES: Clear Crusted 



Discharge. 
FrontaL 



SINUSES: Maxillary 

MOUTH: Normal Open Herpes Stomatiti; 

TONGUE: Normal Moist Dry Injected 

THROAT: Normal Injected Membrane (type)- 

TONSILS: Normal Large Buried Cryptic 

GLANDS: Normal Enlarged Ant-cervical I 



character- 
Etmoid- 



Inflamed Operated Stumps Adenoids— 

ost-cerv. Epitroclear Inguinal Others 



TEETH: No Good 

EARS: Normal Perforation 

NECK: Thyroid 

CHEST: Normal barrel 
LUNGS: 



ayed Approximation good poor. Alveolar abscesses- 
Discharge right left character 

Other findings 

funnel pigeon Rosary Harrison's Groove 



HEART: Area of dullness- 



cm to left of mid-sternal line 

cm to right of mid-sternal line 

6th space in mid-clavicular line 

cm outside, inside, mid-clavicular line 

Irregular Sounds: clear impure 



Soft 
Loud 



presystolic 

systolic 

diastolic 



apex 
pulmonic 
aortic 



-Blood pressure 

tympanitic tender 

right left 



-Blood Pressure- 



LITER: Palpable 
SPLEEN: Palp-bl< 
Kidneys: Right — 



-Boundaries In Mid. Cl.l 



482 



INFANT FEEDING. 



GENITALS: Phimosis Circumcised Undescended Testicle Hydrocele Vaginitis 

Anus Normal Abnormal 

EXTREMITIES: Deformity Acquired Congenital Rickets 



FEET: Arches good flat pronated Posture good poor Gait 

SPINE: Normal Rigid Curvature F 

REFLEXES: Patellar Brudzinski Oppenheim Troussea 

Kernig Babinski Chvostek 

WEIGHT: Present Normal for height 

LENGTH: Present Normal for weight 



ADt. sup. spine to 
CIRCUMFERENCE: Head 



DIET AND HYGIENE. 

Appetite (Especially for Breakfast 
Breakfast Between 
Regularity of meals— hours 
Food dislikes 



Food Idiosyncrasies (milk, cereals, meat, eggs, vegetable 



No. of children in family. 
Milk purchased daily 
Milk taken dally 



Cereal 






Vegetables 


potatoes 


Fruit 






Meat or 


fish 


or eggs 


Coffee 






Tea 






Candy 




How much 


URINE: 




Color 
Sugar 



Rest periods ye: 

Sleep quality 

quantity hours 

No. sleeping in room in bed — 

Fresh air window open 

Out or doors Hours 

Teeth How often brushed 

Bath 



When eaten Constipated yes or no 

LABORATORY AND SPECIAL EXAMINATIONS 

Sp. gr. Reaction 

Acetone Diacetlc Acid 

Blood CastB 



Use of cathartics 



SPECIAL NOSE, THROAT. EAR and SINUS: 



RADIOGRAM OF CHEST. DIGESTIVE TRACT. 



BLOOD i W. B. C. R. B C. 

Vaccination: 

Wasserman Reaction- 

Throat Culture: 

Von Pirquet: negative positive cm. are 

Vaginal Smear 

Electrical Reactions: COC AOC 

Shick Test: 

Skin Test for Proteins: 

Stool Exam, for Parasites: 

Toxin Antitoxin: 

SUMMARY OF DEFECTS FOUND 

Underweight for height pounds per cent 

Carious Teeth No. alveolar abscesses 

Mouth Breather Cryptic Tonsils 

Enlarged Cervical Glands 

Otitis: dry discharging 



Relation AOC to ACC 



APPENDIX. 



483 



OTHER PATHOLOGICAL FINDINGS- 



CONSULTATIONS ORDERED: 

Consultations reports received and operations performcd- 



SOCIAL SERVICE REI>0RT 



Neighborhood 

Bath tub sanitary conditions 

Mother's attitude Remarks, 



SUBSEQUENT TREATMENT 



DATE TEMP. WGT 



484 INFANT FEEDING. 



SUBSEQUENT TREATMENT 






INDEX. 



Abdomen, condition of, in over- 
feeding, 74 
Acetone bodies, 13 
Acetone body adicosis, 394 
Acetonuria, 385 

from inanition, 394 
Acid, excess of, in tissues, 388 

excreted by renal tissues, 388 

hydrochloric, presence of, 3 

lactic, in tissues in acidosis, 
261 

neutralizing of, 389 
Acidity, in stomach of normal 

breast-fed, 243 
Acidosis, 384 

acetone body in, 390 

alkali therapy in, 402 

diet in, 403 

in anhydremia, 266 

in athrepsia, 242, 248 

lactic acid in tissues in, 261 

medical treatment of, 404 

of renal origin, 397 

physiological, at birth, 394 

post-operative, 396 

prognosis in, 400 

pulmonary diseases in, 392 

treatment of, 401 

secondary to burns, 397 

symptoms of, 397 
Acids, cause of excess in intes- 
tines, 241 

volatile, in milk, 105 
Active signs in spasmophilia, 

353 
Air hunger in acidosis, 398 
Albumin milk, cause of in- 
creased intestinal secre- 
tion, 23 



Albumin milk, formulas for, 
444, 445 
in athrepsia, 255 
in diarrhea, 234 
in enteral infections, 300 
in infection, 282 
in beef extract, 433 
water, 432 
Alkali therapy in acidosis, 402 
Amino acids in diarrhea, in 

anhydremia, 261 
Ammonia in urine, neutralized 

by acids, 389 
Anatomy of digestive tract, 1 
Anemia, aplastic, 417 
Banti's disease in, 418 
blood findings in, 413 
blood transfusion in, 423 
causes of, 406 
. chlorotic type of, 416 
following hemorrhage, 409 
hemolytic icterus in, 418 
in prematures, 408 
nutritional disturbances as 

cause of, 410 
of infancy, 405 
pernicious, 4i7 
prognosis of, 421 
splenectomy in, 424 
splenic enlargement in, 413 
symptoms of, 412 
treatment of, 422 
von Jaksch's, 415 
Anions, 15 
Anhydremia, 259 
acidosis in, 266 
changes of blood in, 265 
diagnosis of, 269 
diet in, 274 



(485) 



486 



INDEX. 



Anhydremia, etiology of, 259 

heart action in, 265 

intoxication, 281 

nervous symptoms in, 264 

pathogenesis of, 266 

respiratory manifestations in, 
264' 

symptoms of, 262 

urine in, 264 

water administration in, 270 
Antiscorbutics, fruit as, 381 
Appendix, 425 
Argyrol in diarrhea, 236 
Athrepsia, 237 

causative factors in, 238 

cell hunger as cause of, 239 

diagnosis of, 248 

differentiation from chronic 

infections, 238 
•hunger day in, danger of, 244 

medical treatment of, 257 

pathogenesis of, 239 

prognosis in, 249 

symptoms of, 244 

treatment of, 250 
Atropine, use of, in diarrhea, 
236 

Baby foods (proprietary), 425 
Bacilli in enteral infections, 293 
Bacteria, cause of anemia, 411 
content in milk, 106 
diseases due to, 34 
in enteral infections, 284, 286 
influence of diet on, 30 
intestinal, cause of fermenta- 
tion, 33 
signification of, 29 
invasion in upper intestinal 

tract, 243 
relation to gastro-intestinal 
disturbances, 32 
Barley water, 431 
Bath," hot, 454 
hot and cold packs, 453 



Bath, mustard, 454 
Bile, functions of, 4 
Blood, calcium content in nor- 
mal infants, 316 
changes in acidosis, 265 
findings in anemia, 414 
picture in healthy children, 
469 
in normal infants, 405 
vessels, changes of, in scurvy, 

371 
volume, average, in athrepsia, 
240 
Bone marrow, changes in, in 
scurvy, 368 
salts, increased by phosphorus 
intake, 317 
Bottles and their care, 447 
Bowel irrigation, in overfed, 78 
Rrady's mixture, No. 1, 436 

No. 2, 437 
Breast-milk, cause of excess fat 
in, 77 
conditions influencing qual- 
ity of, 41, 55 
feeding, preventive of 

scurvy, 380 
bow to express, 58 
idiosyncrasy toward, 82 
instructions for expressing, 

58 
insufficient supply, indica- 
tions of, in infant, 69 
method of drawing, 56 
number of daily expres- 
sions, 60 
quantity required by infant, 
68 
Breasts, massage, as applied to, 
71 
care of, 40 

during weaning, 66 
means of stimulating, 70, 71 
steaming of, 71 
Burns as cause of acidosis, 397 



INDEX. 



487 



Butter-flour feeding, 446 
Buttermilk and skimmed milk 
mixtures, 435 

for hospital feeding, 435 

in home, 434 

Calcium, content in milk, 14 

level disturbance a factor in 
rickets, 309 

metabolism, relation of diet 
to, 318 
in spasmophilia, 345 

relation to spasmophilia symp- 
toms, 346 

salt, diminution of, factor in 
spasmophilia, 349 
Caloric content of foods in cor- 
rect feeding, 135 

needs, definite estimation of, 
136 

requirement for artificially 
fed infant, 136 

value of various foods, 138, 
146 
Calories, energy quotient in, 138, 

146 
Camphor, use of in athrepsia, 

257 
Cane and milk sugars, 129 
Carbohydrate, addition to 
breast-milk, in athrep- 
sia, 252, 253 

amount for infant, 153 

amount needed by infant, 130 

as cause of increase in diar- 
rhea, 260 

chemistry of, 11 

disorders due to fermentation 
of, 34 

effect of, on weight, 13 

factor in diarrhea, 221 

fermentation produced by 
bacteria, 33 

in corn syrup, 254 

in infection, 282 



Carbohydrate, in tissues, 13 
increase in severe athrepsia, 

256 
influence on development of 

bacteria, 31 
insufficiency, symptoms of, 

204 
intestinal reaction to, 203 
metabolism of, 12 
precautions in administering, 

130 
starvation, danger of, in 

diarrhea, 234 
to be added to feedings, 142 
use of, 128 
Care of infant's food during 

travel, 449 
Case histories, 465 
Castor oil in convulsions, 356 

in enteral infections, 297 
Cathartics as cause of diarrhea, 

225 
Catheter feeding, 457 
Cations, 14 
Cell hunger, 239 
Cereal water, addition to diet, 
143 
flours, 131 
Chlorine content in milk, 15 
Cholesterin content in milk, 18 
Chvostek's sign in spasmophilia, 

352 
Chymogen milk, 434 

in irritable stomach con- 
ditions, 301 
Codliver oil, phosphorized, in 

rickets, 339 
Colic, 167 

associated with constipation, 

168 
in overfed, 7S 
treatment of, 169 
Colon irrigation and rectal feed- 
ing, 457 
Colostrum, 7 



488 



INDEX. 



Condition of infant, how es- 
timated, 229 
Constipation, 170 
associated with colic, 168 

with soap stools, 205 
boiling milk, as factor in, 111 
diagnosis of, 174 
dietetic errors in, 173 
relieved by addition of 
vegetables in diet, 177 
treatment, 175 

in enteral infections, 302 
Convulsions, castor oil in treat- 
ment of, 356 
due to salt excess, treatment 

of, 403 
result of overfeeding with 

fat, 128 
seditive for, in anhydremia, 
274 
Cream and skimmed milk mix- 
tures, 155 
Crying of infant in overfeed- 
ing, 78 

Daily gains in weight, of pre- 
matures, 96 
Data as to foods and food re- 
quirements, 139 
Debility, congenital, impairment 
of functions in, 79 
prematurity as cause of, 79 
Defective hygiene, factor in 

rickets, 312, 334, 338 
Dextrinized barley, 432 
Diaper, 450 

Diarrhea, as accompaniment of 
acidosis, 398 
cathartics as factors in, 225 
chronic, 235 
chronic disease, as cause of, 

225 
differential diagnosis in, 228 
due to overfeeding, 220 
factors in, 218 



Diarrhea, from infected foods, 
222 

from infections, 223 

from overfeeding, 74 

from subnormal food toler- 
ance, 222 

idiosyncrasy as factor in, 224 

in infections, 290 

increase due to carbohydrates 
and fat, 260 

sequel to nutritional dis- 
orders, 218 

temperature, as factor in, 223 

treatment of, 230 

varieties of, 228 
Diet, clinical findings of, in 
rickets, 311 

constituents of, as factor in 
digestion, 123 

effect of in spasmophilia, 343 

fruit juices and vegetables in 
rickets, 333 

hunger, in diarrhea, 231 

in acidosis, 403 

in anhydremia, 274 

in convalence from enteral in- 
fections, 302 

in late infancy and early 
childhood, 158 

indifferent, in diarrhea, 231 

injury from, 211 

of lactating mothers, factor 
in rickets, 307, 332 

mixed, for young infants, 145 

relation to calcium metabo- 
lism, 318 
Digestion, constituents of diet 
in, 123 

of fat by infant, 127 

of milk, 22 
Digestive tract, anatomy of, 1 
Dilution of milk for prematures 

in first days, 91 
Disaccharides, 11 
Diseases due to bacteria, 34 



INDEX. 



489 



Disorders due to carbohydrate 
fermentation, 34 
dependent on vitamine lack, 
215 
Drugs, effect of, on milk, 42 
Dyspepsia, result of overfeed- 
ing, 75 

Eclampsia, 354 

as result of overfeeding, 75 
Edema, caused by flour injury, 

213 
Eggs, 442 
Endocrine gland theory, in 

rickets, 313 
Enteral infections, diagnosis 
of, 292 
complications of, 292 
diatetic treatment of, 299 
medical treatment of, 298 
stimulants in, 298 
treatment of, 296 
Enteritis, 285 

prognosis in, 295 
Epinephrin, in athrepsia, 257 

in diarrhea, 236 
Erb's sign in spasmophilia, 351 
Excretion, effect of fat on, 15 
of calcium, 14 
of chlorine, 14 
of iron, 14 
of salts, 15, 24 
of sodium, 14 

Farina and other gruels, 432 
Fat, as cause of increase in 
diarrhea. 260 
digestion in infants, 152 
effect on stool formation, 24 
influence, on fermentative 

processes, 31 
metabolism, abnormal, essen- 
tial factor in athrepsia, 
242 
requirement in feeding, 140 



Fats, amount necessary for in- 
fants, 128 
as cause of increased excre- 
tion, 15 
as cause of vomiting, 128 
chemistry of, 10 
in breast-milk, 11 
in gastro-intestinal tract, 11 
in urine, 10 
metabolism of, 10 
necessary for heat energy, 127 
result of excess, 203 
Fatty acids, appearance in 

. stools, 227 
Feces in breast-fed, residue in, 
62 
test for constituents in, 24 
Feeding, artificial, during first 
weeks, 151 
factor in rickets, 309 
in athrepsia, 252 
by catheter, in parenteral in- 
fections, 81 
catheter, in prematures, 87 
diets in late infancy, 158 
example, No. 1, 147 
No. 2, 149 
No. 3, 150 
formulas, 148 
in weak infants, 85 

regular time for beginning, 
90 
method of bottle, 152 
methods with prematures, 86 
mixed, 63 
of prematures, 84 

an individual problem, 92 
first ten days, 93 
requirements by weight, 63 
Feedings, amount of, for pre- 
matures, 95 
artificial, in prematures, 96 

recent progress in, KM) 
boiled buttermilk mixtures, 
for prematures, 97 



490 



INDEX. 



Feedings, chymogen milk in, 98 
during first days, 45 
of prematures, number neces- 
sary per day, 94 
maximum in first ten days, in 

prematures, 96 
number of, in 24 hours, 43 
percentage method of, 117 
quantity and quality of, 97 
required in 24 hours, 141 
top milk, 118 
Ferments, in stomach, 4 
intestinal, 4 
normal in milk, 102 
pancreatic, 4 
Flora of intestines, 28 
Flour ball, 211, 432 
edema from, 212, 213 
injuries, 211 
Fontanelles, closure of, 468 
Food, elements required, per 
pound body weight, 140 
reaction to, in healthy infant, 

197 
refusal in infection, 284 
requirement in estimation of 

diet, 139 
supply, effect on body, from 

insufficient, 240 
tolerance, subnormal, nutri- 
tional disturbance due 
to, 195 
Foods, caloric value of, 138, 146 
diet of artificial, in pathogene- 
sis of nutritional dis- 
turbance, 207 
to be avoided, 161 

taken with caution, 161 
Foodstuffs, classes of, 20 
value of, in scurvy, 365 
Fruits, as antiscobutics, 365, 381 
apple sauce, 442 
orange gelatine, 442 
juice, 19, 41, 145, 153, 365, 
382, 422 



Fruits, prune jelly, 442 
juice, 41 

Galactose in milk, 11 

Gas bacillus, cultured from 
stools, 294 

Gastric juice, present in pre- 
matures, 3 

Gavage, size of meal, important 
in, 2 

General development of infants, 
467 

Glucose administration, in aci- 
dosis, 395, 404 
in athrepsia, 254 
solution, intravenous injec- 
tion of, in athrepsia, 
258 

Glycogen, formation of, 12 
found in new-born, 4 
stored by liver, 12 

Gram-positive bacilli, 28 

Gruel, 432 ■ 

Heat, as cause of nutritional 
disturbance, 196 
artificial, in athrepsia, 258 
Heating pad receptacle, 464 
Hunger day, in athrepsia, dan- 
ger of, 244 
diet in severe athrepsia, 256 
Hydrochloric acid, 3 

Ice-box, home made, 461 
Idiosyncrasy to cow's milk, 186 

toward mother's milk, 57 
Indigestion, gastric, acute, 165 
Infant bed, Hess, 462 

foods, direction for prepara- 
tion of, 431 
Infant's gelatine food, 443 
Infection and nutrition, 276 

as cause of diarrhea, 223 
Infections, etiology, 284 

changes produced by, 280 



INDEX. 



491 



Infections, chronic, 392 
enteral, 284 

pathology of, 287 
sequel to parenteral, 285 
intestinal, inflammation in, 288 
of upper respiratory tract, 392 
of upper respiratory tract, as- 
sociated with acidosis, 
390 
parenteral, 279 

inert fluids in, 81 
relation to scurvy, 362 
symptoms of, 280, 289 
treatment of, 281 
Infectious disorders, acidosis in, 

390 
Intestines, flora of, 28 
large, function of, 5 
relative size, 21 
Intraperitoneal injections, 402 
Intravenous saline injections, 

460 
Iron content in milk, 14 
metabolism, 411 

Rations, 14 

Keller's malt soup, 437 

Lactation, period of, 55 

Lactic acid-corn syrup mixture, 

254 
Lamb and veal broth, 438 
Laryngismus stridulus, 354 
Lavage, 88 

Lecithin, content in milk, 18 
Length increase, first year, 61 
Leukemia, acute lymphatic, 419 

splcnomyelogenous, 421 
Light, action of, in rickets, 312 
Lime water in milk, 144 
Lipoids, 17 
Liver, secretions of, 4 

size of, 2 

Magnesium, content in milk, 14 
Maltose and dextrin compounds, 
131 



Measurements, 467 
Meats, 447 

Metabolism, definition of, 6 
in infections, difficulties in 

study of, 6 
of calcium, in spasmophilia, 

345 
of fat, 10 
of iron, 411 

of minerals in rickets, 313 
of nitrogen, 9 
of phosphorus, 317 

in normal infants, 346 
of salts, in infants, 15 
relation of salts to, 15 
of water to, 16 
Milk, adaptations, 115 

ageing of, a factor in scurvy, 

360 
albumin, 444, 445 

administration, guarded in 

athrepsia, 256 
cause of increased intes- 
tinal secretion, 23 
duration of feeding of, in 

athrepsia, 257 
in athrepsia, 255 
in diarrhea, 234 
in enteral infections, 300 
bacterial content of, 106 
boiling, as factor in constipa- 
tion, 111 
method of, 114 
sterilizing and pasteurizing, 
110 
boiled, advantage over raw, 
112 
buttermilk, in enteral infec- 
tions, 300 
breaking curd in, 144 
breast, as curative agent in 
spasmophilia, 343 
conditions influencing, 41, 

55 
methods of drawing. 56 



492 



INDEX. 



Milk, certified, 107 

versus boiling, 114 - 
chymogen or pegnin, 98 
in enteral infections, 301 
in infection, 284 
cooling, importance of, 107 
cow's, 103 

and human compared, 104 
begin use of, 64 
difference from maternal, 

103 
in aggravation of tetany, 

343 
in anhydremia, 275 
low in antiscorbutic factors, 
360 
digestion of, 22 
dilution, for prematures, 91 

with carbohydrates, 138 
dilutions, 119 
dried, in scurvy, 361 
frozen, effect of, 109 
goat's, in idiosyncrasy, 186 
human, content of, 36 
in athrepsia, 251 
in enteral infection, 299 
in nutritional disorders, 207 
percentage of iron in, 412 
idiosyncrasy as factor in diar- 
rhea, 224 
toward, 186 
human, 82 
in athrepsia, duration of feed- 
ing, 257 
_ inspected, 109 
instruction for expression of 

human, 58 
lime water in, 144 
magnesium content, 14 
metabolism of, 7 
mixed, 110 

underfeeding in, 209 
necessity of clean, 106 
overfeeding, with insufficient 
carbohydrates, 200 



Milk, pasteurizing of, 433 
versus boiling, 113 
percentage method of feed- 
ing, 117 
precaution with, in home, 107 
protein content of cow's, 124 
proteins of, 7 

requirement, daily total of, 44 
salt content of, 132 
skim and cream mixture, 155 
spoiled, nutritional distur- 
bance from, 195 
sugar content in, 105 
whole, undiluted, 116 
Mixed diets for young infants, 

145 
Mixtures, lactic acid-corn syrup, 

254 
Monosaccharides, 11 
Mouth, physiology of, 3 

Xitrogen elements in protein, 
124 
metabolism, 9 

salts, necessary for building 
body, 126 
Nursing, axioms, 38 
contraindications to, 37 
diet of mother in, 38 
general considerations of, 35 
mother, liquids taken by, 70 
regularity in, 42 
successful, signs of, 61 
time limit for, 43 
total period for, in mothers, 

45 
wet-, 46 
Nutritional disturbances, bad 
hygiene as cause in, 196 
classification of, 193 
constitutional anomalies as 

cause of, 196 
differences in, 278 
following spoiled milk, 195 
etiology of, 190 



INDEX. 



493 



Nutritional disturbances, fac- 
tors in, 67 
following underfeeding, 194 
from overfeeding, 194 
general classification of, 198 
general consideration of, 

187 
improper hygiene as cause 

in, 196 
in artificially fed, 162 
increased susceptibility to 

infections from, 277 
infections in, 195 
with diarrhea, 218 
without diarrhea, 200 

Oatmeal and rice water, 432 
Orange juice, 441 

as antiscorbutic, 365 
as cure for scurvy, 382 
in anemia, 422 
in mixed diet for young in- 
fants, 145 
vitamines in, 19 
when to begin giving, 153 
Organs of body, changes of, in 

rickets, 322 
Overfeeding, crying of infant 
in, 78 
eczema in, 75 
pyelitis, result from, 75 
pylorospasm in, 75 
treatment of, 76 
treatment of colic from 78 
symptoms of, 73 
washing of stomach in, 78 

Pancreatic ferments, 4 
Parathyroid feeding, without 

result in spasmophilia, 

357 
theory, in spasmophilia, 348 
Pasteurizing of milk, 433 
Phosphate, excess of, factor in 

spasmophilia, 340 



Phosphorus, content in milk, 15 
excretion, 317 
preventive of rickets, 309 
metabolism of, in normal in- 
fants, 346 
Physiological salt solution for 
removal of meconium. 
91 
Polysacchirides, 11 
Potassium, content of milk, 14 
Powdered milk foods, 430 
Premature infants, methods of 

feeding, 84 
Prematurity, a cause of debility. 
79 
as factor in development in 
rickets, 308 
Preparation of infant food, 431 
Proprietary foods, as deficient 

foods, 380 
Protein requirements for in- 
fants, 126 
Proteins, chemistry of, 7 
content of blood, in normal in- 
fant, 268 
daily amount used by adult, 

125 
digestion in infant, 152 
functions of, 123 
metabolism of, 8 
metabolism in products of, 9 
in cow's milk, ratio of, 103 
in development of intestinal 

organisms, 31 
in stools, 24 
nitrogen constituents of, 124 

elements in protein, 124 
refraction index, in anhydre- 

mia, 268 
requirement in feeding, 140 
result of excess, 203 
Prune jelly, 442 

juice, 441 
Cudding, cornstarch, 443 
custard, 443 



494 



INDEX. 



Pulmonary ventilation, in acido- 
sis, 387 

Pulse and respiration, average 
rate of, 469 

Purgation, castor oil in for new- 
born, 91 

Purpura, 377 

Pyelitis, as result of overfeed- 
ing, 75 

Pylorospasm from overfeeding, 
75 

Pylorus, patency of, 1 

Ouartz lamp, use of, in rickets, 
337 

Recipes, 430 

Record sheets, 470 

Rectal feeding, 457 

Reparative stage in athrepsia, 
251 

Rheumatic fever, as suggesting 
scurvy, 377 

Rheumatism, 165 

Rickets, 304 
codliver oil in, 310, 339 
deformities in, 328 

prevention of, 340 
endocrine gland theory in, 313 
etiology of, 305 
fruit juices for, 333 
hygienic treatment of, 333 
main varieties of, 342 
medicinal, treatment of, 338 
mineral metabolism in, 313 
pathological anatomy of, 319 
pathology of, in prematures, 

324 
prognosis in, 330 
quartz lamp, exposures, 337 

prophylactic agent in, 336 
radio diagnosis in, 329 
relation of tetany to, 342 
seasonal occurrence of, 307 
symptoms of, 325 



Rickets, treatment of, 331 
ultra-violet rays in, 333 
Ringer's solution, administered 
by rectum in prema- 
tures, 91 
in anhydremia, 271 
Rumination, 165 

Saline solutions, 459 
intravenously, 460 
subcutaneously, 459 
technic, 460 
Salts, chemistry of, 14 
content in milk, 132 
excretion of, 16, 24 
function of, 15 

in cow's milk, factor in nu- 
tritional disturbances, 
105 
necessary in nitrogen reten- 
tion, 126 
relation of, to metabolism, 15 
Scurvy, 358 

diagnosis of, 376 
dietetic treatment of, 381 
differentiation from acute 
nephritis, 378 
from osteomyelitis, 378 
from poliomyelitis, 378 
etiology of, 358 
■infections related to, 362 
pathological anatomy in, 367 
prognosis of, 379 
proprietary foods, as factors 

in, 360 
radiological diagnosis of, 375 
resemblance to beriberi, 364 

to pellagra, 364 
response in, to vitamines, 215 
symptoms of, 373 
treatment of, 379 
Sleep, 467 
Spasmophilia, 341 
active manifestations in, 341, 
353 



INDEX. 



495 



Spasmophilia, calcium salt dim- 
inution, as factor in, 
349 
diet in, 355 
latent signs in, 350 
medical treatment in, 356 
parathyroid theory in, 348 
phosphate excess, as factor in, 

349 
prognosis in, 355 
seasonal occurrence of, 344 
symptoms of, 349 
treatment, 355 
Sodium, content in milk, 14 
Soups, 438 
Startoline, 435 

Starvation, as factor in acido- 
sis, 393 
Sterilization of milk, 433 
Stomach, capacity of, 2 
secretions of, 3 
position of, 1 
washing, 455 
Stools, abnormal, 177 
carbohydrate, 185 
characteristics of, in anhydre- 
mia, 263 
in athrepsia, 247 
in flour excess, 227 
in infections, 290 
characteristic types of, 180 
color of, 178 

foamy, in carbohydrate fer- 
mentation, 227 
formation, effect of fat on, 24 
hunger, characteristics of, 25, 

69 
in diarrhea, characteristics of, 

226 
in flour injuries, 213 
in underfed, characteristics 

of, 233 
normal, characteristics of, 25 
of breast-fed babies, 61 
snap, 183, 202 



Stools, associated with consti- 
pation, 205 
tests in, 178 

Sugar content in milk, 105 

Sugars and starches, as cause 
of nitrogen retention, 
126 

Sunlight, as preventive of 
rickets, 307 

Syphilis, 377 

-Tannigin, in diarrhea, 236 
Tea, administration of, in 
athrepsia, 255 
recipe for making, 431 
Technic of intravenous injec- 
tion, 460 
Teeth, number of, at time, 61 

eruption of, 468 
Test, Marriott's, colorimetric, 
398 
for constituents of feces, 24 
Sellard's, in acidosis, 394 
Van Slyke's, in acidosis, 399 
Tetany, predisposition to, in 
prematures, 343 
relation to rickets, 342 
Tomatoes as antiscorbutic, 366 
Trousseau's sign, 353 

Underfeeding, as factor in 

rickets, 308 
Urea, in urine, 9 
Uremia, presence of, in anhy- 

dremia, 261 
Urine, ammonia in, neutralied 
by acids, 389 
ammoniacal in disturbances 
without diarrhea, 205 
average daily quantity, 469 
characteristics of, in scurvy, 

374 
examinations, period to be 

covered by, 6 
fals in. 10 
in anhydremia, 264 



496 



INDEX. 



Van Slyke's test, in acidosis, 399 
Vegetables, 446 

for infants, 145 
Vitamines, 18 

classification of, 364 
deficiency in lactating 
mothers, as factor in 
rickets, 306 
improvement from, in athrep- 

sia, 255 
lack of, in flour injury, 212 
lack, no relation to spasmop- 
hilia, 344 
relation to deficiency diseases, 

362 
result from, in malnutrition, 

215 
specifics of, 367 
Volatile acids, in milk, 105 
Vomiting, 162 

from overfeeding, 74 

in anhydremia, 263 

in infection, 284 

in overfed, washing stomach 

for, 78 
treatment of, 166 
Von Jaksch's anemia, 415 

Water, albumin, 432 

administration in acidosis, 
401 
in athrepsia, 250 



Water, amount administered to 
prematures in twenty- 
four hours, 91 
injection in peritoneal cavity, 

technic of, 272 
lack of, dangerous, 134 
to be added to feedings, 142 
requirement of, 44 
metabolism of, 16 
Weaning, care of breasts dur- 
ing, 66 
indications for, 65 
Weight, affect of carbohydrates 
on, 13 
an estimate of progress, 121 
average, 466 

daily gains in prematures, 96 
fluctuation in. cause of, 241 
gain for nursing infants, 61 
loss in anhydremia, 263 
in athrepsia, 238 
in infections, 290 
Wet-nurse, diet of, 53 
garments for, 53 
hygiene of, 52 
requirements of, 47 
work of, 54 
Whey, 434 

White cell count, average, 469 
line of Fraenkel, 376 
of egg and digested gruel, 
432 



